Office Use Only
Date Received		Received By			Date to Traffic			Date from Traffic
	Single Residential		Field			New Road (subdivision)
	Multi Residential		Commercial			Temporary (construction)
Access Permit #:				Expiration Date:			NOI #

Please Complete All Areas Of Application

Property Owner:				Owner Phone Number:
Applicant Name:				Applicant Phone Number:
Property Address:
Tax Schedule Number:	-	-	-
Subdivision Name:

By Signing Below, the Applicant Accepts Responsibility For:

* Locating and identifying all easements, property lines, existing and proposed structures.

* Allowing 10 to 15 days processing time.

* Installing the driveway in accordance with the applicable sections of the Mesa County

Access Policy.

* Access installation must occur before the 60 day expiration date.

Applicant Signature

Date

Sketch Plan: In the space below please draw a site plan illustrating the following:
	An outline of property lines with dimensions
	Location and outline of proposed driveway
	All easements and right-of-way on the property
	All adjacent streets and the street names
	Any water course that crosses the property (drainage streams, rivers)
Please be as accurate as possible as any of the above information that is not shown in the sketch will result in a delay of obtaining an Access Permit.