Form TR-0410 "Encroachment Permit Application Checklist - Special Events" - California

What Is Form TR-0410?

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 January 1, 2020;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form TR-0410 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form TR-0410 "Encroachment Permit Application Checklist - Special Events" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
ENCROACHMENT PERMIT APPLICATION CHECK LIST - SPECIAL EVENTS
TR-0410 (REV 01/2020)
NAME OF APPLICANT OR ORGANIZATION
TRACKING NUMBER
DISTRICT / COUNTY / ROUTE / POSTMILE
Applicants and their authorized agents must follow section 514 of the Encroachment Permits Manual.
APPLICATION
All boxes must be filled out (write “N/A” if not applicable).
Work description within State highway right-of-way must be comprehensive.
The “Standard Encroachment Permit Application” (form TR-0100) must be signed by the applicant or organization.
If signed by an agent, attach a letter of authorization. Note: Box 28 is the applicant’s information and box 29 is the
authorized agent’s.
Signatures are required on both the application and the letter of authorization.
Detailed event related information.
Number of event participants and spectators.
Duration of event including preparation and staging.
Rules for event participants and spectators.
Information on shuttle buses and escort vehicles (routes and times).
Cleanup arrangements for roadway and roadside.
Media and local business communication plan.
Plan for providing advance notification to, and coordinate with, hospitals, emergency services, and public transit agencies.
Arrange for passage of these vehicles through or around the event.
Provide 2 names and 24-hour contact numbers for the purposes of lane closure provisions (required only if there is a detour or
lane closure).
Facilities must be in compliance with the Americans with Disabilities Act.
Is alcohol or marijuana proposed to be served at the event?
Minimum deposit of $492 (payable to Caltrans), unless applicant is a government agency (fee-exempt).
PLANS
Six (6) event route maps.
Six complete sets of Traffic Control/Traffic Management plans (for detours) folded to 8 ½” x 11”, signed, stamped with license
expiration date and date stamped by a California Registered Civil or Traffic Engineer.
Location of staging area for event participants and spectators.
Location and number of aid stations and portable restrooms.
SUPPORTING DOCUMENTS*
Proof of non-profit status or verification by the Internal Revenue Service 501C.
Resolution of support from all impacted governments indicating formal approval of the special event and detour
plans. Local support of the activity may be evidenced by an ordinance, resolution, written consent, or locally
issued permit.
Documentation from the California Highway Patrol or local law enforcement that they are aware of the event and that special
enforcement will be provided if necessary.
A certificate of liability insurance naming the State of California, California Department of Transportation, the
directors, officers, employees, and/or agents of the State of California and/or of the California Department of
Transportation as additional insured. The certificate must be in the amount based on the risk level associated with the event.
COMPLIANCE WITH STREETS AND HIGHWAYS CODE SECTION 682.7 (required)
My special event awards prize compensation to competitors in gendered categories. For any participant level that receives prize
compensation, I certify that prize compensation for each gendered category will be identical at each participant level.
I certify that my special event does not award prize compensation to competitors in gendered categories regardless of
participant level.
SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
PRINT OR TYPE NAME
TITLE
DATE
NOTES:
*Forms are available at: https://forms.dot.ca.gov/
ADA NOTICE: For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 654-6410, TTY 711, or write to Records and
Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
ENCROACHMENT PERMIT APPLICATION CHECK LIST - SPECIAL EVENTS
TR-0410 (REV 01/2020)
NAME OF APPLICANT OR ORGANIZATION
TRACKING NUMBER
DISTRICT / COUNTY / ROUTE / POSTMILE
Applicants and their authorized agents must follow section 514 of the Encroachment Permits Manual.
APPLICATION
All boxes must be filled out (write “N/A” if not applicable).
Work description within State highway right-of-way must be comprehensive.
The “Standard Encroachment Permit Application” (form TR-0100) must be signed by the applicant or organization.
If signed by an agent, attach a letter of authorization. Note: Box 28 is the applicant’s information and box 29 is the
authorized agent’s.
Signatures are required on both the application and the letter of authorization.
Detailed event related information.
Number of event participants and spectators.
Duration of event including preparation and staging.
Rules for event participants and spectators.
Information on shuttle buses and escort vehicles (routes and times).
Cleanup arrangements for roadway and roadside.
Media and local business communication plan.
Plan for providing advance notification to, and coordinate with, hospitals, emergency services, and public transit agencies.
Arrange for passage of these vehicles through or around the event.
Provide 2 names and 24-hour contact numbers for the purposes of lane closure provisions (required only if there is a detour or
lane closure).
Facilities must be in compliance with the Americans with Disabilities Act.
Is alcohol or marijuana proposed to be served at the event?
Minimum deposit of $492 (payable to Caltrans), unless applicant is a government agency (fee-exempt).
PLANS
Six (6) event route maps.
Six complete sets of Traffic Control/Traffic Management plans (for detours) folded to 8 ½” x 11”, signed, stamped with license
expiration date and date stamped by a California Registered Civil or Traffic Engineer.
Location of staging area for event participants and spectators.
Location and number of aid stations and portable restrooms.
SUPPORTING DOCUMENTS*
Proof of non-profit status or verification by the Internal Revenue Service 501C.
Resolution of support from all impacted governments indicating formal approval of the special event and detour
plans. Local support of the activity may be evidenced by an ordinance, resolution, written consent, or locally
issued permit.
Documentation from the California Highway Patrol or local law enforcement that they are aware of the event and that special
enforcement will be provided if necessary.
A certificate of liability insurance naming the State of California, California Department of Transportation, the
directors, officers, employees, and/or agents of the State of California and/or of the California Department of
Transportation as additional insured. The certificate must be in the amount based on the risk level associated with the event.
COMPLIANCE WITH STREETS AND HIGHWAYS CODE SECTION 682.7 (required)
My special event awards prize compensation to competitors in gendered categories. For any participant level that receives prize
compensation, I certify that prize compensation for each gendered category will be identical at each participant level.
I certify that my special event does not award prize compensation to competitors in gendered categories regardless of
participant level.
SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
PRINT OR TYPE NAME
TITLE
DATE
NOTES:
*Forms are available at: https://forms.dot.ca.gov/
ADA NOTICE: For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 654-6410, TTY 711, or write to Records and
Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.