Convex Mirror for Private Driveway or Street

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DPW Form 40(1) County of Hawaii 9/8/09 DEPARTMENT OF PUBLIC WORKS ENGINEERING DIVISION INSTALLATION OF A CONVEX MIRROR FOR A PRIVATE DRIVEWAY OR STREET INSTRUCTIONS FOR APPLICANT: 1) Fill out top portion of form and sign at the bottom. 2) Mail to TRAFFIC DIVISION 108 RAILROAD AVENUE, HILO, HI 96720 APPLICANT: MAILING ADDRESS: NAME OF COUNTY ROAD /STREET MIRROR IS TO BE LOCATED ON: PHONE: TAX MAP KEY: REQUIRED ATTACHMENT: Location map showing the County road /street, property lines, approximate location of the private driveway or street, any sight distance obstructions and the proposed location of the convex mirror. FOR OFFICE USE ONLY This form shall be routed and processed in the following order: 1. TRAFFIC DIVISION: Based on the legal speed limit, the recommended stopping sight distance along the County road /street is (check one): ❑ 360 feet for 45 mph ❑ 200 feet for 30 mph ❑ 305 feet for 40 mph ❑ 155 feet for 25 mph or less ❑ 250 feet for 35 mph ❑ There is sufficient stopping sight distance along the County road to see a vehicle emerging from the driveway in accordance with the above indicated stopping sight distance. This form is forwarded to the Engineering Division with a recommendation that this request should be denied. ❑ There is insufficient stopping sight distance along the County road to see a v ehicle emerging from the driveway in accordance with the above indicated stopping sight distance. This form is forwarded to the Highway Maintenance Division for further processing. By: 2. HIGHWAY MAINTENANCE DIVISION: Date: ❑ We are able to increase stopping sight distance, at a reasonable cost using in -house resources, along the County road to meet the minimum distance indicated in the above Item 1 by the Traffic Division. This form is forwarded to the Engineering Division with a recommendation that this request should be denied. Questions shall be directed to Work is scheduled to begin in NAME at PHONE ❑ We are unable to increase stopping sight distance, at a reasonable cost using in -house resources, along the County road to meet the minimum distance indicated in the above Item 1 by the Traffic Division. This request is forwarded to the Engineering Division for further processing. By 3. ENGINEERING DIVISION: ❑ Approved for further processing ❑ Denied - See above By: Date: Date: The undersigned understands that this form will be used for review purposes by the Department of Public Works. The issuance of the Convex Mirror Installation Permit is subject to the approval of this request. Applicant will be notified by mail. By APPLICANT'S SIGNATURE County of Hawai'i is an Equal Opportunity Provider and Employer Date: