Form 1058Form 1058 Permit to Construct Access Driveway Facilities
on Highway Right of Way Page 1 of 2
(Rev. 12/17)
Design of facilities shall be as follows and/or as shown on sketch on page 2 and is subject to conditions stated below:2.
The undersigned hereby agrees to comply with the terms and conditions set forth in this permit for construction and maintenance
of an access driveway on the state highway right of way.
1.
Subject to the Access Driveway Policy described on page 2 and the following:
.County, located
instore, retail mall, farm, etc.) access driveway on the highway right of way abutting highway number
(residential, convenience reconstruct a construct / hereinafter called the Permittee, to
,The Texas Department of Transportation, hereinafter called the State, hereby authorizes
PERMIT NUMBER:
REQUESTOR
30.979148, -97.020690
4-DIGIT
GPS*
LATITUDE, LONGITUDE
NAME
MAILING ADDRESS
ROADWAY
HWY NAME
2-DIGIT EX. 01SECTION
SH 121
CONTROL
FOR TxDOT'S USE
Jonathan Schindler
5200 State Highway 121
PHONE NUMBER
*GLOBAL POSITIONING SYSTEM COORDINATES AT INTERSECTION OF DRIVEWAY CENTERLINE WITH ABUTTING ROADWAY
(817) 488-4960
CITY, STATE, ZIP Colleyville, Texas 76034
TxDOT ENTER PERMIT NUMBER HERE
3. Maintenance of facilities constructed hereunder shall be the responsibility of the Permittee, and the State reserves the right to
require any changes, maintenance or repairs as may be necessary to provide protection of life or property on or adjacent to the
highway. Changes in design will be made only with approval of the State.
All construction of materials shall be subject to inspection and approval by the State.
4. The Permittee shall hold harmless the State and its duly appointed agents and employees against any action for personal injury or
property damage sustained by reason of the exercise of this permit.
5. Except for regulatory and guide signs at county roads and city streets, the Permittee shall not erect any sign on or extending over
any portion of the highway right of way, and vehicle service fixtures such as fuel pumps, vendor stands, or tanks and shall be
located at least 12 feet from the right of way line to ensure that any vehicle services from these fixtures will be off the highway right
of way.
6. The State reserves the right to require a new access driveway permit in the event of a material change in land use or change in
driveway traffic volume or vehicle types.
7. This permit will become null and void if the above-referenced driveway facilities are not constructed within six (6) months from the
issuance date of this permit.
8. The Permittee will contact the State’s representative
telephone, () , at least twenty-four (24) hours prior to beginning the work authorized by this permit.
The requesting Permittee will be provided instructions on the appeal process if this permit request is denied by the State.9.
Date of Issuance State Authorized Representative
The undersigned hereby agrees to comply with the terms and conditions set forth in this permit for construction and maintenance of an
access driveway on the highway right of way.
Signed:Date:
(Property owner or owner’s representative)
DocuSign Envelope ID: 3E7E1942-8E98-46D3-A6FC-3B7F87D2CADA
940/387-1414
5/6/2020
Gary Matthews / Ramon Ramos
Form 1058 (Rev. 12/17)
Page 2 of 2
Access Driveway Policy
Title 43 Texas Administrative Code (Transportation), Chapter 11 (Design), Subchapter C (Access Connections To State Highways) and
the "Access Management Manual" establish policy for the granting of access and the design, materials, and construction of driveways
connecting to state highways. All driveway facilities must follow this policy.
For a local contact for your TxDOT Driveway Permit Request visit: http://www.txdot.gov/inside-txdot/district.html. You can click on the
section of the map closest to your location to find the local TxDOT office. You can also click on the drop down box below the map to
find the district for your county.
TxDOT Driveway Permit Request Contact
Sketch of Installation
(Use additional sheets as needed)
DocuSign Envelope ID: 3E7E1942-8E98-46D3-A6FC-3B7F87D2CADA