Form MT-120 A 
Revised 11/2014
	New Jersey Department of Transportation	Application No.     	
To complete form, refer
to instructions on other
side.	APPLICATION FOR HIGHWAY OCCUPANCY	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.      	
				M.P.      	
				Amt. Received      	
    Submit in Duplicate				Check No.      	
Print or Type		CASH WILL NOT BE ACCEPTED		Date Received      	
				(DEPT. USE ONLY)	

APPLICATION	     	
MADE BY		
		
MAILING	     	     	     	     	
ADDRESS					
	(Street)                                                                                    	(City)	(State)	(Zip Code)	
	     	
TELEPHONE NUMBER		
On Behalf of	     	
	(Self, Tennant, Lessee)	
Requests	     	Permit for the Use and Occupancy of the Right-of-Way	
	(Type of Permit)		
of State Highway No.	     	Milepost	     		     	, County of 	     	
                                                                    (Municipality)	
Located as Follows:	     	
                                   (Describe Exact Location, Direction and Reference with Street, Stream, Milepost)	
for the installation, operation and maintenance of the following described project: 	    	

	
     	

If a permit is granted that includes the installation or construction of items within State Right of Way, I or we agree to accept full 
maintenance responsibility for such items, which may include but not be limited to:  flower beds, trees, benches, trash receptacles,
decorative curbing, lighting and sidewalks.  A comprehensive list of items will be provided to the State along with a plan sheet identifying
the items and their location/s.  Said list of items and plan sheet/s will be attached hereto and become part of this Permit.
 
Subject to the provisions of the New Jersey Tort Claims Act, N.J.S.A. 59:1-1 et seq.,I or we will be responsible for personal injuries and
property damage caused by the actions of ourselves, our agents, servants and employees which arise out of or which are claimed to
arise out of this Permit.  Any claim for such personal injury or property damage must be filed in accordance with N.J.S.A. 59:8-1 et seq.

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.	
	
* 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 DATA IS NECESSARY FOR A COMPLETE UNDERSTANDING OF THE REQUEST. A TRAFFIC SAFETY SETUP AS PER THE “MANUAL ON UNIFORM TRAFFIC CONTROL” IS REQUIRED WITH APPLICATION.”
THE DEPARTMENT WILL NOT BE RESPONSIBLE FOR ANY ERRORS OR MISINFORMATION GIVEN IN THE APPLICATION AND/OR ON THE ACCOMPANYING PLANS.	

If a permit is granted, I or we, agree to comply with the rules and regulation of the New Jersey Department of Transportation and 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 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.

Included is the required Application Fee, in the amount of  $	
	
I understand no refunds will be made after an application has been filed.		

     		     	
 (Signature of Agent or Authorized Representative)		  (Title)                                                      (Type or Print)	

     		     	
 (Print)		  (Date)	

INSTRUCTIONS TO APPLICANT FOR HIGHWAY PERMITS
An applicant requesting a permit to occupy highway right of way must obtain 
and complete the proper application form listed below according to the type of
work to be performed.

	APPLICATION FOR BRIDGE ATTACHMENT         	NJ 16:41     (Form MT-105 A)		
	APPLICATION FOR ACCESS DRIVEWAY		NJ 16:47     (Form MT-32 A)		
	APPLICATION FOR DRAINAGE			NJ 16:41     (Form MT-39 A)		
	APPLICATION FOR ERECTION OF POLE		NJ 16:41     (Form MT-33 A)		
	APPLICATION FOR UTILITY OPENING		                NJ 16:41     (Form MT-17 A)		
	APPLICATION FOR HIGHWAY OCCUPANCY	                NJ 16:41     (Form MT-120 A)		
	APPLICATION FOR CHARITABLE SOLICITATION	NJ 16:40     (Form MT-120 A)		
			
	INSTRUCTIONS FOR COMPLETING THIS FORM
APPLICATION FOR HIGHWAY OCCUPANCY		
			
	Below is the schedule of  fees and types of requests that may be granted and are covered
by completing this form. Be sure to indicate the type of permit that you are applying for on the application and submit the required fee.			
			
	CASH WILL NOT BE ACCEPTED – APPLICATION FEES ARE NON-REFUNDABLE		
	DO NOT SUBMIT PERMIT FEE WITH APPLICATION		
			
	FEE SCHEDULE AND TYPES OF PERMITS THAT APPLY TO THIS FORM		
			
TYPE OF REQUEST	NUMBER    UNIT	APPLICATION FEE	PERMIT FEE	    EXTENSION	
Curb, Sidewalk,	0 – 200       Linear Feet (LF)	$395.00	$130.00	$130.00	
Handicapped ramp	Greater than 200 LF	$790.00	$265.00	$265.00	

Landscaping, Tree Trim,
Vegetation Control and
Unclassified Landscaping	UNIT	$395.00	$130.00	$130.00	

Pedestrian Overpass and/or
Pedestrian Underpass	1 UNIT	$790.00	$265.00	$265.00	

Grading	UNIT	$330.00	$100.00	$100.00	

Guiderail	0 –200      Linear Feet (LF)	$395.00	$130.00	$130.00	
	Greater than 200 LF	$790.00	$265.00	$265.00	
Test Holes or Borings	1 to 5	$230.00	$65.00	$65.00	
	Greater than 5	$460.00	$165.00	$165.00	
Monitoring Wells	1 to 5	$230.00	$65.00	$65.00	
	Greater than 5	$460.00	$165.00	$165.00	
Crosswalks	1 to 4	$230.00	$65.00	$65.00	
	Greater than 4	$460.00	$165.00	$165.00	
Bus Shelters or Benches		$395.00	$130.00	$130.00	
Banners, Decorations or
Temporary Announcement or
Guide Signs					
	1 to  5	$165.00	$35.00	$35.00	
	Greater than 5	$230.00	$65.00	$65.00	
Parades or Gatherings		$165.00	$35.00	$35.00	
Temporary Use		$460.00	$165.00	Not Applicable see N.J.A.C. 16:41-6.10	
Detours on/off State Highway		$395.00	$130.00	$130.00	

Lane or Shoulder Closings on State Highways		$230.00	$65.00	$65.00	

Automatic Traffic Counting Procedure		$65.00	$35.00	$35.00	
Charitable Solicitation		$25.00	(per day)    $10.00	For each day, or part thereof, of proposed solicitation N.J.A..C.16:40-10.1	
Wireless Communications					
Site Survey	Annual	$790.00	$265.00	$265.00	
Railroad Grade Crossings	Unit	$525.00	$200.00	$200.00	
Miscellaneous	Unit	$395.00	$130.00	$130.00	
The Department will not be responsible for any errors or misinformation given in the application and on the accompanying plans