Permittee Name
Address
Address
City, State, Zip
Phone Number (999-999-9999)
Fax (999-999-9999)

Location where work is to be completed
Township Street or Address
Address line 2
Applicant is an
Anticipated Start Date
Anticipated Completion Date
The road surface is improved to a width of: (feet)
Distance from center line of roadway to gutter or ditch: (feet)
Distance from center line of roadway to right-of-way line: (feet)
Number of poles to be erected:
Nearest distance from center line of roadway to structure (feet)
Distance of proposed work along road (feet)
Will improved surface fo the road be opened?
Yes    No
If yes, Approximate area of openings in improved surface
(Sq Ft)

Length of trench along road (feet)
Depth of trench below surface (inches)
Description and Purpose of work

A full schedule of permit fees for this form are in this PDF file:
Highway Occupancy Permit Fees


For most fees, choose:
-any Applicable Options AND
-enter Quantity for that Option (1, 2, 3, etc)

(some options do NOT have quantity)


Application Fees ( all applicable categories)
1) a) Utility Fee ($50)
1) b) Driveways
 Qty:
1) c) Other ($20, bank removal, sidewalk and curb)
2) Supplemental (each six month extension)($10 ea submitted change)
 Qty:
3) Emergency Permit Card ($5 each card)
 Qty:

Following fees are applied to location reviews and inspections of permitted work
5)a) Each Minimum Use Driveway ($10)
 Qty:
5)b) Each Low Volume Driveway ($20)
 Qty:
5)c) Each Medium Use Driveway ($35)
 Qty:
5)d) Each High Volume Driveway ($50)
 Qty:

6) Surface Openings (fees based on total linear ft of opening being permitted)

6a) Total Liniear feet of opening (each 100 ft increment or fraction thereof):
a)(i) Opening in Pavement ($30)
 Qty:
a)(ii) Opening in Shoulder ($20)
 Qty:
a)(iii) Opening Outside Pavement and Shoulder ($10)
 Qty:

6b) If a longitudinal opening simultaneously occupies two or more highway areas, identified in section a), only the higher fee will be charged. Linear distances to nearest foot.

7) Surface Openings of Less than 36 Sq Ft (service connections performed independantly of underground facility installation, pipe line repairs) (each opening)
7)i) Opening in Pavement ($30)
 Qty:
7)ii) Openings in Shoulder ($15)
 Qty:
7)iii) Openings outside Pavement and Shoulder ($10)
 Qty:

If an opening simultaneously occuples two or more highway access areas identified in subparagraphs (i)-(iii), only the higher fee will be charged.

8) Above Ground Facilities (poles, guys and/or anchors if installed independently of poles)
8a) Up to 10 physically connected above-ground facilities $20 (each continuous group)
 Qty:
8b) Additional above ground physically connected facilities (each pole with appurtenances)
 Qty:
9) Crossings $80 (overhead triples, conveyors or pedestrian walkways and upgrade subways or mines)
 Qty:

10) Seismograph-Vibroseis Method (Prospecting for oil, gas)
10)a) First Mile ($50)
10)b) Each additional mile or fraction thereof ($5 ea)
 Qty:
11) Non-Emergency Test Holes in Pavement or Shoulder ($5 each hole)
 Qty:
12) Other ($20 bank removal, sidewalk and curb)