NW Region Utilities Office / Utility Permit or Franchise Application
Limited Access Encroachment
Variance Request
Justification Questionnaire
Permit/Franchise No.: / Date:
SR / MP Limits:
Applicant:
Installation Description:

INSTRUCTIONS: Please complete Section 1-Justification of Variance Proposal. All questions must be answered. Questions requiring an explanation should be answered thoroughly and completely. Unanswered questions could delay approval of you utility permit or franchise application. Section 2-Regional Considerations are to be completed by WSDOT Regional Utilities Office.

SECTION 1-Justification of Variance Proposal(to be completed by applicant)

1. Reason for Installation Inside Limited Access Right of Way

Explain why it is unusually difficult or impossible to install the proposed utility outside Limited Access Right of Way:

2. Alternatives Routes Considered

Identify all other routes and/or installation alternatives that were considered and why they were rejected. Provide a plan or sketch showing these alternative routes their relation to the proposed route:

3. Basis for Selection of Proposed Route

Explain the basis for selecting the chosen route and why it is critical to the alignment of the proposed utility:

4. Cost Justification

If cost is a basis for rejection of alternatives considered but rejected, explain in detail what makes the cost prohibitive:

5. Impacts to Limited Access Facility

Identify and explain any impacts or potentially adverse effects on the design, construction, or stability of the limited access facility or its appurtenances due to the proposed installation:

6. Impacts to Traffic and Pedestrian Movements

Identify and explain any impacts or potentially adverse effects to traffic and/or pedestrian movements or effects on the overall operation of the highway that may occur due to the proposed installation:
  1. Utility Maintenance

Will utility maintenance be necessary during the life of this utility? / Yes / No
If yes, explain the nature and frequency of maintenance operations, how it will be managed including proposed access to the utility, traffic control methods, and other aspects of maintenance operations:

8. Existing Conditions

Provide photographs showing existing conditions in at least four directions at the location of the proposed installation. Include any vegetated areas, geologic features or other natural features, guardrail, drainage facilities, or other items that will be impacted by this proposal:

9. Proposed Installation Details

Provide a roadway cross-section and/or profile showing the vertical alignment of the proposed installation within the Right of Way. Information should be legible using standard civil engineering drafting conventions and should include: (1) location of all existing utilities, (2) width of traveled lanes, turn lanes, shoulders, medians, and any widened areas outside of shoulders, (3) angle and depth of proposed installation in relation to existing grade, ditching and/or embankments. Dimension all information from the centerline of the highway horizontally and from appropriate datum vertically.

10. Additional Information

Provide any additional information that you feel supports this variance request:

Applicant Certification and Signature

To the best of my knowledge the information provided herein by me, employees under my supervision, or consultants hired by me, is complete and accurate and factually represents all aspects of the proposed utility installation:
Signature / Date
Print name
Title

SECTION 2-Regional Considerations(to be completed by WSDOT)

Administrative Assessment and Coordination

Is there a need for a notice of filing? / Yes / No
If yes, explain why:
Will the proposal have an adverse effect on the structural integrity, maintenance, appearance, or operation of the highway? / Yes / No
If yes, explain why:
Will the utility installation affect design or construction of currently programmed projects? / Yes / No
If yes, list the project and explain how the proposed utility installation will affect it:
Have appropriate design and construction offices been given an opportunity to review and comment on the proposed installation? / Yes / No
If so, what steps will be taken to coordinate utility installation with affected projects:

Region Utility Office Recommendation

What is the Regions recommendation regarding approval of this application: / Approve / Disapprove
Explain reasoning for approval or disapproval

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