Applicant Information:

Organization Name:    Date:

City or county (if different from above):

Contact Person Name and Title:

Address:

Email:  Phone:

ODOT Region:  District:  ACT:

1.  Type of project:  Sidewalks [ ]  Bike Lane Striping [ ]  Shoulder Widening [ ]

Intersection Improvement [ ]  Pedestrian Crossing Improvement [ ]  Other [X]

If Intersection Improvement, Pedestrian Crossing Improvement, or other please describe:

2.  Street, road or highway project is located on:

Indicate whether it is a state highway or a local facility, or both in case of an intersection improvement

Cross street or other reference point: beg: end:    

Length in feet, where applicable:  Side of street (Both, N, S, E, W, etc.):

3.  a. Total project cost, including engineering & local match:

b.  State’s share (Grant amount you are seeking, $200,000 maximum):

c.  
Local share:  

d.  Other funding source: (Describe)

4.  Can the project be divided into two phases? If it can, please indicate the two sections, costs and your priority for completion. This may affect project selection if there is insufficient funding for your entire project as submitted:

5.  Briefly define the problem and describe the proposed solution. Include the following information:

•  Describe the need, the current conditions and how the project will improve the situation.  Note: see questions 19 & 20 for drawings

•  Does the project fill in missing gaps or provide connectivity to other facilities?    & map requirements

6.  
Is the project included in a local, adopted plan?  Y [X] N [ ]

Please identify:

If not, has the need been identified elsewhere?  Y [ ] N [ ]

Where?

7.  Have local elected officials formally expressed support for this project? *  Y [X] N [ ]

a.  Are there currently accesses, driveways, or on street parking within the project limits?  Y [ ] N [X]

b.  If so, have local elected officials indicated support for any proposed changes? *  Y [ ] N [ ]

c.  Are you prepared to hold public hearings, if required?  Y [X] N [ ]

 * Please fill in appropriate box on signature page

8.  Does the proposed facility lie within existing road or street rights-of-way?  Y [X] N [ ]

Projects in parks or abandoned railway lines are not eligible.

If not, this project is not eligible.

9.  
Does an agency other than the applicant have jurisdiction over the right-of-way?  Y [X] N [ ]

If yes, who?

a.  Do they concur with your project request? Please fill in appropriate box on signature page  Y [X] N [ ]

b.  Will they agree to maintain the facility? Please fill in appropriate box on signature page  Y [X] N [ ]

10.  Is the proposed project to be included in a larger project?  Y [ ] N [X]

(Projects that add sidewalks or bikeways as part of road construction or reconstruction are not eligible. Projects that tie into other work, such as surface preservation, utility or drainage work, are eligible, even encouraged.)

Please describe project, timeline, and other funding sources:

11.  Who will primarily be served by this project? (e.g. school children, commuters, recreational users, seniors, disabled, etc.)

13.  Does the proposed facility provide a link to transit or park-and-ride facilities?  Y [X] N [ ]

If yes, describe:

14.  Does the project include a railroad crossing?  Y [ ] N [X]

If yes, do the railroad and the ODOT Rail Crossing Safety Unit concur with your project request?  Y [ ] N [ ]

(ODOT Rail Crossing Safety Unit phone number: 503-986-4273) Please fill in appropriate box on signature page

15.  Are there any Travel information Council (TIC) signs located within the project?  Y [ ] N [X]

If yes, please contact the TIC (503-378-2244) to coordinate replacement or relocation.

16.  Will the project accommodate both pedestrians and bicyclists?  Y [X] N [ ]

If not, is the other mode provided for, or will it be? Describe:

17.  Are any bridges, tunnels, retaining walls or other structures required?  Y [ ] N [X]

If yes, describe:

18.  Describe any other outstanding project features or local circumstances that reviewers should be aware of. If the space below is insufficient, you may instead attach a 1 page letter, at a font size no smaller than 12 pt.

19.  On a separate 8.5"X11" sheet of paper, attach a typical cross-sections of the existing roadway or a diagram of the intersection or crossing treatment and proposed solution; include width, surfacing, and other features.

DO NOT attach large plans or blueprints.

Is the cross-section or diagram included?  Y [X] N [ ]

20.  Include a black & white 8.5” x 11” vicinity map that shows where the project lies within the community. Indicate adjacent land use and nearby destinations, as well as existing or planned pedestrian and/or bicycle facilities, within reasonable walking or biking distance of the project.

(See page 167 of the Oregon Bicycle and Pedestrian Plan for an example of coding to be used, as well as approximate scale.)

Is the vicinity map included?  Y [X] N [ ]

Mail application package to:

Michael Ronkin

Bicycle & Pedestrian Program Manager

Traffic Management Services, 5th floor

355 Capitol St NE

Salem OR 97301-3871

503-986-3555 fax 4063