Form CEM-5773NSPP "Curb Ramp (Non-standard Plan - Perpendicular) Americans With Disabilities Act (Ada) Compliance Inspection Report" - California

What Is Form CEM-5773NSPP?

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 (NON-STANDARD PLAN - PERPENDICULAR)
AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
Page 1 of 9
CEM-5773NSPP (NEW 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
County
City
Route
Route Name
Cross Street
CURB RAMP INFORMATION
Postmile/Station
Latitude (y)
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
Project Plan Sheet
2010
Northeast
Other
2015
Southwest
Other
Southeast
Applicable Design Bulletin
Mid-Block
DIB 82-05
ADA CURB RAMP COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2, curb ramp complies with the attached project plan?
Yes
No
N/A
Based on the field measurements shown on page 3, curb ramp complies with the attached project plan?
Yes
No
N/A
Based on the field measurements shown on page 4, curb ramp complies with the attached project plan?
Yes
No
N/A
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
Project plan sheet showing non-standard plan - parallel curb ramp is attached to this compliance inspection report.
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 (NON-STANDARD PLAN - PERPENDICULAR)
AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
Page 1 of 9
CEM-5773NSPP (NEW 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
County
City
Route
Route Name
Cross Street
CURB RAMP INFORMATION
Postmile/Station
Latitude (y)
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
Project Plan Sheet
2010
Northeast
Other
2015
Southwest
Other
Southeast
Applicable Design Bulletin
Mid-Block
DIB 82-05
ADA CURB RAMP COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2, curb ramp complies with the attached project plan?
Yes
No
N/A
Based on the field measurements shown on page 3, curb ramp complies with the attached project plan?
Yes
No
N/A
Based on the field measurements shown on page 4, curb ramp complies with the attached project plan?
Yes
No
N/A
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
Project plan sheet showing non-standard plan - parallel curb ramp is attached to this compliance inspection report.
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 (NON-STANDARD PLAN - PERPENDICULAR)
AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
Page 2 of 9
CEM-5773NSPP (NEW 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Passageway Type
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (NON-STANDARD PLAN - PERPENDICULAR) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes against those shown on the contract plan sheet.
Insert in the blanks (___) provided below the curb ramp slopes and dimensions shown on the construction detail plan sheet.
Verify that the curb ramp planned slopes and dimensions comply with the ADA standards.
Ramp
Ramp
Ramp
Left Flare
Right Flare
Gutter
Gutter
Road Surface
Slope
Cross Slope
Width
Slope
Slope
Slope
Cross Slope
Cross Slope
(x.x%)
(x.x%)
(inches)
at Back of Curb
at Back of Curb
(x.x%)
(x.x%)
within 2'
(x.x%)
(x.x%)
from Ramp
(x.x%)
A1
B1
C1
D1
E1
F1
G1
H1
A2
B2
C2
F2
G2
H2
A3
B3
C3
G3
H3
% or less?
% or less?
" or
% or less?
% or less?
% or less?
% or less?
% or less?
greater?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
N/A
Yes
No
Yes
No
Gutter width is
N/A
N/A
24" or greater.
ADA Standard
ADA Standard
ADA Standard
ADA Standard
ADA Standard
ADA Standard
ADA Standard
ADA Standard
8.3% max
2.0% max
48" min.
10.0% max
10.0% max
2.0% max
5.0% max
5.0% max
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 (NON-STANDARD PLAN - PERPENDICULAR)
AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
Page 3 of 9
CEM-5773NSPP (NEW 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Passageway Type
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (NON-STANDARD PLAN - PERPENDICULAR) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes against those shown on the contract plan sheet.
Insert in the blanks (___) provided below the curb ramp slopes and dimensions shown on the construction detail plan sheet.
Verify that the curb ramp planned slopes and dimensions comply with the ADA standards.
Top Landing
Top Landing
Top Landing
Top Landing
Detectable
Detectable
Slope
Cross 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
% or less?
% or less?
" or
" or
Extends full
Minimum 36"?
greater?
greater?
width and less
than 1" gap on
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
either sides
Yes
No
ADA Standard
ADA Standard
ADA Standard
ADA Standard
2.0% max
2.0% max
48" min.
48" min.
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 (NON-STANDARD PLAN - PERPENDICULAR)
AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
Page 4 of 9
CEM-5773NSPP (NEW 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Passageway Type
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (NON-STANDARD PLAN - PERPENDICULAR) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes against those shown on the contract plan sheet.
Insert in the blanks (___) provided below the curb ramp slopes and dimensions shown on the construction detail plan sheet.
Verify that the curb ramp planned slopes and dimensions comply with the ADA standards.
Left Side
Left Side
Right Side
Right Side
Conforming Sidewalk
Conforming Sidewalk Cross Slope
Conforming Sidewalk
Conforming Sidewalk Cross Slope
Slope within 4' of top landing
of ramp within 4' of top landing
Slope within 4' of top landing
of ramp within 4' of top landing
(x.x%)
(x.x%)
(x.x%)
(x.x%)
O1
P1
Q1
R1
O2
P2
Q2
R2
O3
Q3
Yes
No
Yes
No
Yes
No
Yes
No
% or less?
% or less?
% or less?
% or less?
If "No," is the sidewalk adjacent to
If "No," is the conforming sidewalk
If "No," is the sidewalk adjacent to
If "No," is the conforming sidewalk
the roadway and the sidewalk grade
a transition to an existing sidewalk?
the roadway and the sidewalk grade
a transition to an existing sidewalk?
Yes
No
Yes
No
does not exceed the roadway
does not exceed the roadway
grade?
Yes
No
N/A
grade?
Yes
No
N/A
If "Yes," the 2.0% or less
If "Yes," the 2.0% or less
requirement does not apply.
requirement does not apply.
ADA Standard
ADA Standard
ADA Standard
ADA Standard
5.0% max
5.0% max
2.0% max
2.0% max
or roadway grade
or roadway grade
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 (NON-STANDARD PLAN - PERPENDICULAR)
AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
Page 5 of 9
CEM-5773NSPP (NEW 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Passageway Type
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (NON-STANDARD PLAN - PERPENDICULAR) FIELD INSPECTION CHECKLIST
No.
Requirement
Compliant
Photo
Remarks
Detectable warning surface was on the Authorized Material List?
Yes
No
Yes
No
Yes
No
Detectable warning surface is yellow in color?
Yes
No
Yes
No
Yes
No
Detectable warning surface is in compliance with standard
Yes
No
Yes
No
Yes
No
plan A88A detail Raised Truncated Dome for dome diameter
and height?
Detectable warning surface is in compliance with standard
Yes
No
Yes
No
Yes
No
plan A88A detail Detectable Warning Surface for truncated
dome spacing?
Detectable warning surface edge nearest the street is in
Yes
No
contact with the back of curb per standard plan?
N/A
Mark N/A if installed per contract plan construction detail.
Yes
No
Detectable warning surface edge nearest the street is installed
Yes
No
Yes
No
as shown on the project plans?
N/A
Detectable warning surface 5-year manufacturer's warranty
Yes
No
Yes
No
Yes
No
is on file?
Curb ramp surface has a broom finish, which provides slip
Yes
No
Yes
No
Yes
No
resistant surface?
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
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
elongated openings oriented perpendicular to dominate
Yes
No
Yes
No
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.