Form CEM-5773FG "Curb Ramp (Case F or G) Americans With Disabilities Act (Ada) Compliance Inspection Report" - California

What Is Form CEM-5773FG?

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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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE F OR G) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 9
CEM-5773FG (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
Ramp Case
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Case F
Northwest
2010 Standard Plan A88A
2010
Case G
Northeast
2010 Revised Standard Plan A88A Dated:
2015
Southwest
2015 Standard Plan A88A
Other
Southeast
2015 Revised Standard Plan A88A 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 A88A?
Yes
No
Based on the field measurements shown on page 3 curb ramp complies with standard plan A88A?
Yes
No
Based on the field measurements shown on page 4 curb ramp complies with standard plan A88A?
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 F OR G) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 9
CEM-5773FG (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
Ramp Case
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Case F
Northwest
2010 Standard Plan A88A
2010
Case G
Northeast
2010 Revised Standard Plan A88A Dated:
2015
Southwest
2015 Standard Plan A88A
Other
Southeast
2015 Revised Standard Plan A88A 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 A88A?
Yes
No
Based on the field measurements shown on page 3 curb ramp complies with standard plan A88A?
Yes
No
Based on the field measurements shown on page 4 curb ramp complies with standard plan A88A?
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.
Page 2 of 9
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE F OR G) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
CEM-5773FG (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Ramp Case
Intersection Quadrant
Ramp
Location Number
Route Name
Case F
Northwest
Southwest
Single
Cross Street
Case G
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE F or G) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Ramp
Ramp
Ramp
Case G
Case G
Gutter
Gutter
Road Surface
Slope
Cross Slope
Width
Left Flare Slope
Right Flare Slope
Slope
Cross Slope
Cross Slope
(x.x%)
(x.x%)
(inches)
at Front Edge
at Front Edge
(x.x%)
(x.x%)
within 2'
of Sidewalk
of Sidewalk
from Ramp
(x.x%)
(x.x%)
(x.x%)
A1
B1
C1
D1
E1
F1
G1
H1
A2
B2
C2
F2
G2
H2
A3
B3
C3
G3
H3
7.7% or less?
1.7% or less?
49.75" or
9.2% or less?
9.2% or less?
1.7% or less?
4.4% or less?
5.2% or less?
greater?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
N/A
Gutter is 24" or
N/A
N/A
more 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.
Page 3 of 9
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE F OR G) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
CEM-5773FG (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Ramp Case
Intersection Quadrant
Ramp
Location Number
Route Name
Case F
Northwest
Southwest
Single
Cross Street
Case G
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE F or G) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Top Landing
Top Landing
Top Landing
Top Landing
Detectable
Detectable
Cross Slope
Slope
Width
Depth
Warning
Warning
(x.x%)
(x.x%)
(inches)
(inches)
Surface Width
Surface Depth
(inches)
(inches)
I1
J1
K1
L1
M1
N1
I2
J2
K2
L2
M2
N2
I3
J3
K3
L3
1.7% or less?
1.7% or less?
49.75" or
49.75" or
Extends full width
Minimum 36"?
greater?
greater?
and less than 1"
gap on either
Yes
No
Yes
No
Yes
No
Yes
No
side?
Yes
No
Yes
No
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.
Page 4 of 9
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE F OR G) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
CEM-5773FG (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Ramp Case
Intersection Quadrant
Ramp
Location Number
Route Name
Case F
Northwest
Southwest
Single
Cross Street
Case G
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE F or G) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Left Side
Left Side
Right Side
Right Side
Conforming Sidewalk
Conforming Sidewalk
Conforming Sidewalk
Conforming Sidewalk
Slope within 4'
Cross Slope within 4'
Slope within 4'
Cross Slope within 4'
of Top Landing
of Top Landing
of Top Landing
of Top Landing
(x.x%)
(x.x%)
(x.x%)
(x.x%)
O1
P1
Q1
R1
O2
P2
Q2
R2
O3
Q3
5.2% or less?
1.7% or less?
5.2% or less?
1.7% or less?
Yes
No
Yes
No
Yes
No
Yes
No
If "No," is the sidewalk
If "No," is the conforming
If "No," is the sidewalk
If "No," is the conforming
adjacent to the roadway
sidewalk a transition to an
adjacent to the roadway
sidewalk a transition to an
and the sidewalk grade
existing sidewalk?
and the sidewalk grade
existing sidewalk?
does not exceed the
Yes
No
does not exceed the
Yes
No
roadway grade?
roadway grade?
If "Yes," the 1.7% or less
If "Yes," the 1.7% or less
Yes
No
N/A
requirement does not apply.
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.
Page 5 of 9
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE F OR G) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
CEM-5773FG (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Ramp Case
Intersection Quadrant
Ramp
Location Number
Route Name
Case F
Northwest
Southwest
Single
Cross Street
Case G
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE F or G) 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.