Form CEM-5773CM "Curb Ramp (Case Cm) Americans With Disabilities Act (Ada) Compliance Inspection Report" - California

What Is Form CEM-5773CM?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the California Department of Transportation;
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Download a fillable version of Form CEM-5773CM by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE CM) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 9
CEM-5773CM (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
CURB RAMP INFORMATION
Location Number
County
City
Route
Route Name
Cross Street
Latitude (y)
Postmile/Station
Intersection Control
Construction Type
Ramp
None
New
Single
Longitude (x)
Street Grade (%)
Stop/Yield
Retrofit
Dual Ramp 1
Signalized
Dual Ramp 2
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Northwest
2010 Standard Plan A88B
2010
Northeast
2010 Revised Standard Plan A88B Dated:
2015
Southwest
2015 Standard Plan A88B
Other
Southeast
2015 Revised Standard Plan A88B Dated:
Applicable Design Bulletin
Other
DIB 82-05
Mid-Block
ADA CURB RAMP COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2 curb ramp complies with standard plan A88B?
Yes
No
Based on the field measurements shown on page 3 curb ramp complies with standard plan A88B?
Yes
No
Based on the field measurements shown on page 4 curb ramp complies with standard plan A88B?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 5?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 6?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 7?
Yes
No
This section must be completed if no is marked for any question indicating that a curb ramp is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Curb ramp is ADA compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the curb ramp inspection report and find that the constructed curb ramp is in compliance with ADA standards.
Resident Engineer (print name)
Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE CM) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 9
CEM-5773CM (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
CURB RAMP INFORMATION
Location Number
County
City
Route
Route Name
Cross Street
Latitude (y)
Postmile/Station
Intersection Control
Construction Type
Ramp
None
New
Single
Longitude (x)
Street Grade (%)
Stop/Yield
Retrofit
Dual Ramp 1
Signalized
Dual Ramp 2
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Northwest
2010 Standard Plan A88B
2010
Northeast
2010 Revised Standard Plan A88B Dated:
2015
Southwest
2015 Standard Plan A88B
Other
Southeast
2015 Revised Standard Plan A88B Dated:
Applicable Design Bulletin
Other
DIB 82-05
Mid-Block
ADA CURB RAMP COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2 curb ramp complies with standard plan A88B?
Yes
No
Based on the field measurements shown on page 3 curb ramp complies with standard plan A88B?
Yes
No
Based on the field measurements shown on page 4 curb ramp complies with standard plan A88B?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 5?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 6?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 7?
Yes
No
This section must be completed if no is marked for any question indicating that a curb ramp is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Curb ramp is ADA compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the curb ramp inspection report and find that the constructed curb ramp is in compliance with ADA standards.
Resident Engineer (print name)
Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE CM) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 2 of 9
CEM-5773CM (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Ramp
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE CM) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Road Surface
Landing
Landing
Landing
Landing
Gutter
Gutter
Cross Slope
Slope
Cross Slope
Width
Depth
Slope
Cross Slope
within 2'
(x.x%)
(x.x%)
(inches)
(inches)
(x.x%)
(x.x%)
from Ramp
(x.x%)
A1
B1
C1
D1
E1
F1
G1
A2
B2
C2
D2
E2
F2
G2
A3
B3
C3
D3
F3
5.2% or less?
1.7% or less?
1.7% or less?
59.75" or greater for perpendicular
47.75" or
1.7% or less?
4.4% or less?
crossing?
greater?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
N/A
Yes
No
N/A
47.75" for parallel crossing?
Gutter is 24" or
more wide.
Yes
No
N/A
Remarks
Inspection by (print name)
Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE CM) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 3 of 9
CEM-5773CM (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Ramp
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE CM) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Conforming Sidewalk
Ramp
Ramp
Ramp
Conforming Sidewalk Slope
Cross Slope within 4 feet
Slope
Cross Slope
Width
within 4 feet of ramp
of Ramp
(x.x%)
(x.x%)
(inches)
(x.x%)
(x.x%)
H1
I1
J1
K1
L1
H2
I2
J2
K2
L2
H3
I3
J3
K3
L3
7.7% or less?
1.7% or less?
47.75" or
5.2% or less?
1.7% or less?
greater?
Yes
No
Yes
No
If "No," is the sidewalk adjacent to
If "No," is the conforming sidewalk
Yes
No
Yes
No
Yes
No
the roadway and the sidewalk
a transition to an existing sidewalk?
grade does not exceed the
Yes
No
roadway grade?
If "Yes," the 1.7% or less
Yes
No
N/A
requirement does not apply.
Remarks
Inspection by (print name)
Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE CM) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 4 of 9
CEM-5773CM (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Ramp
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE CM) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Gutter
Gutter
Road Surface
Detectable
Detectable
Slope
Cross Slope
Cross Slope
Warning
Warning
(x.x%)
(x.x%)
within 2 feet from ramp
Surface Width
Surface Depth
(x.x%)
(inches)
(inches)
M1
N1
O1
P1
Q1
M2
N2
O2
P2
Q2
M3
N3
O3
Q3
1.7% or less?
4.4% or less?
5.2% or less?
Extends full
Minimum
width and less
36 inches?
Yes
No
than 1 inch gap
Yes
No
Yes
No
N/A
Yes
No
on either side?
Gutter is 24" or more
Yes
No
wide.
Remarks
Inspection by (print name)
Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE CM) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 5 of 9
CEM-5773CM (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Ramp
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE CM) FIELD INSPECTION CHECKLIST
No.
Requirement
Compliant
Photo
Remarks
1
Detectable warning surface was on the Authorized Material List?
Yes
No
Yes
No
Yes
No
2
Detectable warning surface is yellow in color?
Yes
No
Yes
No
Yes
No
Detectable warning surface is in compliance with standard
3
plan A88A detail Raised Truncated Dome for dome diameter
Yes
No
Yes
No
Yes
No
and height?
Detectable warning surface is in compliance with standard
4
plan A88A detail Detectable Warning Surface for truncated
Yes
No
Yes
No
Yes
No
dome spacing?
Detectable warning surface edge nearest the street is in
5
contact with the back of curb projection? If answer is yes,
Yes
No
Yes
No
Yes
No
then mark item 6 N/A.
Detectable warning surface edge nearest the street is
Yes
No
6
installed as shown on the project plans?
Yes
No
Yes
No
N/A
Mark N/A if installed per standard plan.
Detectable warning surface 5-year manufacturer's warranty
7
Yes
No
Yes
No
is on file?
Curb ramp surface has a broom finish, which provides slip
Yes
No
Yes
No
Yes
No
8
resistant surface?
9
Are all changes in surface level less than ¼”?
Yes
No
Yes
No
Yes
No
For any utility pull boxes, manholes, or vaults within the
boundary of curb ramp are they flush with the finished curb
Yes
No
10
ramp surface?
Yes
No
Yes
No
N/A
Mark item N/A if there are no utility pull boxes, manholes, or
vaults.
For openings or gratings located within the boundary of curb
ramp, are spaces less than ½” in one direction and are
Yes
No
Yes
No
Yes
No
11
elongated openings oriented perpendicular to dominate
N/A
direction of travel?
Mark item N/A if there are no openings or gratings.
Remarks
Field inspection checklist completed by (print name) Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.