Form MT-33A    11/2014	NEW JERSEY DEPARTMENT OF TRANSPORTATION	APPLICATION
NUMBER      	
	APPLICATION FOR ERECTION OF POLE	COUNTY      	
SUBMIT IN DUPLICATE		
The required fee must accompany this application,
either by money order or check, payable to the New
Jersey Department of Transportation.

- CASH WILL NOT BE ACCEPTED -		MUNICIPALITY      	
  Please Print or Type				ROUTE NO.      	
				M.P.      	
				AMT. RECEIVED      	
				CHECK NO.      	
APPLICATION			DATE
RECEIVED      	
MADE BY	     			
	                                                     (Utility Company)	(DEPARTMENT USE ONLY)	
MAILING	     	     	     	     			
ADDRESS							
                        (Street)                                               (City)                                     (State)               (Zip Code)		
TELEPHONE NUMBER	     		
			
To erect pole (s) or pole appurtenance (s) for the purpose of installing overhead wires. (Refer to definition on back side).	
			
Number of pole (s) or pole appurtenance (s) to be erected or relocated	     	
			
Voltage not to exceed	     	volts.    Work to be completed by (date)	     	
			
On State Highway No.	     	in	     	
	                                                                                       (City, Town, Township or Borough)	
County of	      	.  Give approximate location from	     	
	      (Name of County)			
     	
(Intersecting Street, Stream or Landmark)	
General purpose of work	     	
     	
     	
     	
     	

* 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.
      	
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)	
		
	Erection of Pole or Pole Appurtenances        Unit	Application		Permit		Extension	
				    					
	0 – 10		                                          Unit		    $330.00		$100.00		$100.00	
	Greater than 10		                            Unit  	    $625.00	              $200.00                $200.00	
		
APPLICATION FEES ARE NON-REFUNDABLE	

If a permit is granted, I or we, agree to comply with the rules and regulations of the New Jersey Department of Transportation and the conditions 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 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 application will be started until the final permit is approved and issued.

	Included is the required Application Fee, in the amount of $	     	

     							     				     	
(Signature of Agent or Authorized Representative)			(Title)				(TYPE OR PRINT)	
	
     									     	
(Print or Type Your Name)							(Date)	

CONDITIONS

I, we, herewith agree to accept and comply with the following:
The permit is for the designated purpose only. If the installation in the future requires an adjustment or relocation, a new permit must be secured.
The cost of construction work and material will be entirely at the Permittee’s expense. The Department will not share in any expense whatsoever or do any construction work pertaining to this project.
The terms and conditions set forth in this permit to erect or relocate poles at the above location and as shown on the attached plan.
All construction work authorized herein will conform with the rules and regulations of the New Jersey Department of Transportation and conditions included herein and on reverse side of this form.
All work will be done to the satisfaction of the Department.
No changes or alterations may be made at any time without written permission from the N.J.D.O.T.
No work in connection with this permit will be started until it is approved and issued. Notice will be given to the appropriate Region office 24-hours prior to commencing work.
After the construction work under this permit is completed, notification shall be given to the Region office that the work has been completed and is ready for final inspection and approval, by the Department.

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 mature 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 FOR TRAVELING PUBLIC
The permittee shall provide all necessary safeguards, such as barricades, lights, etc., for the protection of the public during the progress of the work, and until such work is entirely completed.

PROTECTION FROM OVERHEAD CROSS-OVERS
All high-tension wires crossing highways are to be secured to the pole pins on either side and special safety devices for the protection of the traveling public in such cases must be used when required by the Department. Where high-tension wires are strung to the underside of bridges, passageways, etc., through which the highway passes, necessary precaution must be taken to insure proper anchorage. Energized lines must be lead sheathed or armored cable. Except where special permission is granted, all wires of any nature crossing over the highways must not be less than eighteen feet above the highway.

RELOCATION OF LINE
Poles that conflict with construction shall be removed to a new location approved by the Department.

INTERFERENCE OF POLES WITH SIGNS
Where the proposed erection of poles interferes with existing Department of Transportation advisory, directional or regulatory signs or devices, the location of the poles shall be changes so that total visibility of the installations will be unimpaired.

SHADE TREES
When the erection of poles requires the removal or trimming of shade trees on State Department of Transportation property, the location of the trees shall be shown on the sketches accompanying the application together with the type of trimming required. Permission will be granted for the removal or trimming of trees after investigation by the Department of Transportation Landscape forces. Routine trimming will be considered upon application by letter indicating specific locations. All Work shall be subject to the supervision and approval of the Department representative.

EXCAVATION AND RESTORATION
There shall be no interference with structures on, over or under the highway. Interference with drainage installations must be avoided. Work shall be conducted to eliminate interference with subsurface utilities and their appurtenances unless permission for interference has been obtained from the proper authorities. Upon completion of work the area disturbed shall be properly restored and all excess material if any shall be removed.

SPECIAL CONDITIONS
The Department reserves the right to impose special conditions in special cases.

DEFINITIONS

“Pole Appurtenance” – means any attachment to a utility pole which occupies ground surface area at a distance greater than one (1) foot from the base of the pole or which creates a low overhead clearance of less than 13½ feet. The following items are examples of pole appurtenances: Guy cables, guy anchors, and low mounted transformer supports.

The following items are not pole appurtenances: Call boxes, climbing rungs, transmission lines, crossarms, high transformers, and conduit risers.