CERTIFICATION OF SCOPE OF WORK FOR RESURFACING PLANS

PROJECT NO: __________________ PIN: ____________ Project Length (Mile): _________

DESCRIPTION: ____________________________________________________________

COUNTY: __________________

Disturbed Acreage:	___ Less Than 1 Acre	______ Greater Than 1 Acre

Row or Easements Required:	___ Yes	______ No

The subject resurfacing project is limited to the following items:

☐Cold Planning Existing Asphalt

☐Resurfacing

☐ Safety Edge

☐Pavement Markings

☐Installation of Rumble Strips / Stripes

☐ Raised Pavement Markings

☐Sign Replacement or Upgrades

Safety Upgrades

☐ Center Line Rumble Stripe

☐Installation of Skid Resistant Surfaces

☐Existing Guardrail height adjustment

☐End Terminal (Type 38, 21, and 13) Remove, Upgrade, or new Installation

☐ Install Earth Pad

☐Install new or upgrade existing to self-restoring / low maintenance attenuator

☐Remove, Install, and/or Repair Substandard Bridge Rail

☐ Add 2 ft. wide shoulder at locations where there is no existing shoulder

☐Improve roadway superelevation (No Grading or Pavement Reconstruction)

☐Sight distance correction (intersection and/or stopping)

☐Install Breakaway Sign Support hardware

☐Remove, relocate, delineate Road Side obstacles (i.e. trees) located within the clear zone

Drainage Maintenance

☐Clean/ reshape roadside Ditch

☐Stabilize eroded channel/bank

☐Install a drainage pipe safety head wall (parallel or Perpendicular) if inlet or outlet located

within the clear zone

Pedestrian Accessibility and Bicycle Accommodation

☐Install Handicap Ramps

☐Install Handicap Rams on side roads to maintain continuity/accessibility

Refer to TDOT Long Range Multimodal Transportation Plan (contact Bicycle/Pedestrian

Coordinator) if the subject highway is planned to incorporate,

☐Pavement Marking and Signing for Bike Route

☐Pavement Marking and Signing for Bike Lane

Work Zone Safety

☐Significant Project Determination

☐Temporary Traffic Control

☐Detour

☐Other: _____________________________

☐Other: _____________________________

I certify that the scope of the subject resurfacing and safety project is limited to the items listed above.

____________________________________	___________ Regional Resurfacing Coordinator	Date

____________________________________	___________

Civil Engineering Manager 1	Date

In the event that additional items are added to the scope of work during plans development, complete the section below and resubmit to the Environmental Office.

ADDENDUM TO SCOPE OF WORK FOR RESURFACING PLANS

The following has been added to the original scope of work for the subject resurfacing project:

______________________________________________________________________________

____________________________________	___________

Regional Resurfacing Coordinator	Date

____________________________________	___________

Civil Engineering Manager 1	Date