Form MT-105A 
Revised 11/2014
	New Jersey Department of Transportation	Application No.     	
	APPLICATION FOR BRIDGE ATTACHMENT	County      	
		Municipality      	
		The required fee must accompany this
application, either by money order or
check payable to the New Jersey
Department of Transportation		Route No.      	
 *   Submit in Duplicate				Structure No.      	
(Print or Type)				Amt. Received      	
		CASH WILL NOT BE ACCEPTED		Check No.      	
APPLICATION	Date Received      	
MADE BY	     	(DEPT. USE ONLY)	

THROUGH ITS AGENT	     	
	                       (Name and Title)	
TELEPHONE NUMBER (Area Code)	     	
MAILING 
ADDRESS	     	     	     	     	
	 (Street)                                                                   (City)                                                 (State)                                          (Zip Code)	
To Make an Attachment to Bridge	 ON      OVER     	 Route No. 	     	in	     	
		                                                                                                 (Municipality)	
County of	     	 at	     	
                                                                                                            (State Location Exactly in Reference to intersection)	
     	
(Road, River, Stream or Other Distinct Landmark)	
For the purpose of	     	
	                                                                      (Describe Fully)	
     	
     	
     	

* NOTE: SUBMIT TWO (2) COPIES OF THIS APPLICATION AND SIX (6) COPIES OF A DETAILED PLAN DRAWN TO SCALE SHOWING THE PROPOSED INSTALLATION AND WHATEVER ADDITIONAL DATA IS NECESSARY FOR A COMPLETE UNDERSTANDING OF THE REQUEST. “A TRAFFIC SAFETY SET UP, PER THE MANUAL ON UNIFORM TRAFFIC CONTROL, IS REQUIRED WITH APPLICATION.”

Where a municipal or public utility corporation has entered into an agreement or filed a bond with the State of New Jersey the following shall be completed:	

Covered by bond dated	     	Covered by agreement dated	     	
				
FEE SCHEDULE	
APPLICATION		PERMIT		
(Only Submit Required Application Fee)	(Do Not Submit Permit Fee With Application)	
	Bridge Attachments	Unit	Application	Permit	Extension	
	0-100			LF	          $395.00	          $130.00	         $130.00	
	Greater than 100		LF	          $790.00	          $265.00  	         $265.00	
APPLICATION FEES ARE NON-REFUNDABLE	
	
The Department shall reserve the right to demand from the applicant, as a condition of any permit, a certified check in an amount sufficient to guarantee or insure proper maintenance or restoration of the area disturbed. If it becomes necessary that the Department forces, for any reason, are required to make repairs, the cost of such work shall be deducted from the principal and the remainder, if any, shall be returned after the project has been completed and accepted. If the amount of the guarantee is less than the cost of the additional work, the applicant shall be billed for the balance due.	

If a permit is granted, I or we, agree to comply with the rules and regulation of the New Jersey Department of Transportation as set forth in the conditions included therein and on the reverse side of this form. In addition, I or we, understand that N.J.S.A. 27:7-44.1 makes any violation of the provisions of the permit subject to a fine (Not exceeding $100.00 per day) and civil action for the costs of prosecution as well as civil action for trespass to remove any non-conforming use. No work in connection with this application will be started until the final permit is approved and issued.

     		     	
 (Signature of Agent or Authorized Representative)		(Date)	
			
     		     	
(Title) (TYPE OR PRINT)		 (Applicant) (PRINT OR TYPE NAME)	

CONDITIONS

Location of Bridge Attachment, installation, design, details, and plan requirements shall be in accordance with the provisions of section 34A of the Department of Transportation Design Manual for Bridges and Structures.

NOTICE PRIOR TO CONSTRUCTION

The permittee shall notify the Region Office of the Construction and Maintenance Unit at least seventy-two (72) hours prior to starting work in order that the Department may have a representative at the site.

PROTECTION OF THE GENERAL PUBLIC

The permittee shall properly safeguard all work performed under permit and if considered necessary, maintain sufficient warning lights, Departmental approved signs and safety devices for the protection of the general public at all times, until the project has been completed.

PROTECTION FROM SUITS

The permittee shall defend, indemnify, protect and save harmless the State and its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages of whatever kind or nature arising out of or claimed to arise out of, any negligent act, error, or omission of the permittee, its agents, servants, and employees in the performance of the work covered by this permit.

PROTECTION OF STRUCTURES

The proposed installation shall in no way obstruct or interfere with the water way or with the free and clear use of the space under the viaduct or bridge.

MATERIAL, CONSTRUCTION, AND MAINTENANCE

Materials and workmanship used in construction affecting highway property shall be in accordance with the New Jersey Department of Transportation standard specifications for road and bridge construction (Including supplements) dated 1983.

The construction and maintenance of the proposed installation shall be at the sole expense of the applicant and at no cost to the State. If the maintenance of the installation unduly interferes with the maintenance of a part of the State’s structure, applicant will maintain such portion of the State’s structure. Whenever it becomes necessary for the state to make repairs to its structure, applicant will upon notice from the State, protect and/or relocate if necessary its installation during the time the repairs are being made by the State.

INSPECTION

All materials, construction and maintenance in connection with the installation shall be subject to inspection and approval of the Department.

TERMINATION OF PERMIT

Permits will not be issued for a period in excess of 12 months. If extension time is needed for the completion of the work, approval may be obtained by letter of request and accompanied by an extension fee of twenty dollars ($20.00); and if the Department deems it necessary a new application must be filed. The permit issued in pursuance of these rules and regulations shall apply only to the viaduct or bridge therein referred to. In the event that the viaduct or bridge therein referred to shall be subsequently destroyed, demolished, relocated, or abandoned, the rights granted by such permit shall cease and terminate.

SPECIAL CONDITIONS

This permit is subject to all municipal ordinances, rules and regulation. The Department of Transportation may impose special conditions in special cases.