ࡱ> Y[X'` ebjbj :.   ,kJ6QQQ\^^^>D3I$Kh NJ (/"Q((J?%J$$$(8 \$(\$$ $ 8"$\;J0kJ$NZN$N $8Q:$k QQQJJQQQkJ(((( APPENDIX A1 - APPLICATION FORM City of Hampton MOVING AND HAULING PERMIT APPLICATION Public Works Traffic Engineering & Operations 419 N. Armistead Avenue Hampton, VA 23669 PHONE: # (757) 726-2919; FAX # (757) 726-2829 or e-mail completed application to lblades@hampton.gov  DATE: _________________________ TYPE OF PERMIT REQUESTED: : $ 75.00 SINGLE TRIP / MOVE DATE __________________ $ 200.00 BLANKET _____ $ 150.00 SUPER LOAD / MOVE DATE __________ $ 200.00 MOBILE CRANE ______ $ 75.00 HOUSE / MOVE DATE : ___________ COMPANY NAME: ____________________________________________ PHONE #: _______________________ ADDRESS: _____________________________________ FAX #: ________________________________________ CITY/STATE/ZIP: _______________________________________________________________________________ ROUTING FROM (ORIGIN): _____________________________ TO (DESTINATION): _______________________________ PREFERRED ROUTE OF TRAVEL: _________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ITEM(S) TO BE MOVED: _________________________________________________________________________ SINGLE TRIPS ONLY: TRUCK LICENSE _____________________ TRAILER LICENSE ___________________ OVERALL SIZE REQUEST HEIGHT: _____ FT _____IN WIDTH: _____FT _____IN LENGTH: _____FT _____IN VEHICLE LOAD/TRAILER OVERHANG: FRONT _________ft/in, SIDE _________ft/in, REAR _________ ft/in. WEIGHT REQUEST Axle spacing and weight displacement estimates are required in case of extremely heavy load. VEHICLE GROSS WEIGHT/VEHICLE COMBINATION/LOAD _____________________________________LBS SINGLE __________ LBS TRI _____________ LBS OTHER AXLE __________ LBS TANDEM ________ LBS QUAD __________ LBS OTHER AXLE __________ LBS WHEEL BASE (MEASURE FRONT CENTER AXLE TO REAR CENTER AXLE) ______________FT MINIMUM NUMBER OF AXLES ON VEHICLE OR VEHICLE COMBINATION: ______________ The permittee, its agents, employees, officers and assigns assume all responsibility and liability for any injury to persons or damage to public or private property, caused directly or indirectly, by the transportation of vehicles and loads under a permit. Furthermore, the permittee, it agents, employees, officers and assigns agree to save and hold harmless the City of Hampton, its agents, employees, and officers from any and all claims, demands, actions, judgments, executions, damages or proceedings for any and all personal Injury, and injuries to property real or personal, public or private, caused by or arising out of; directly or indirectly, from the transportation of the vehicle and/or load under a permit SIGNATURE: __________________________________ PRINT NAME: __________________________________ CERTIFICATION OF CLEARANCE CITY OF HAMPTON MOVING/ HAULING PERMITS OFFICE 419 North Armistead Avenue, Hampton, Va. 23669 757-726-2919 FAX 757-726-2829 DATE: ________________ To: Public Works Traffic Operations/Hauling Permits Office 419 N. Armistead Avenue Hampton, VA 23669 This is to certify that I have checked all horizontal and vertical clearances Between____________________ (origin) and _____________________(destination) via The following route: ______________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___ Map Attached I can maintain a 3 minimum vertical or 12 horizontal clearance(s) between the overall extremities of the following vehicle/load; width__________ (ft.& in.) height___________ (ft.& in.) length ____________(ft.& in.) without reservation. It is further understood that pursuant to the Citys Moving and Hauling Policy the permittee is responsible for all vertical and horizontal clearances. ___ I will furnish a front escort vehicle equipped with an over-height pole (hot pole) extended a minimum of 3 inches higher than the permitted height of the vehicle/load to ensure safe travel. ___ I will use a minimum of one front and one rear escort vehicle to ensure safe travel. ___ I will use a Traffic Control / Police Extra Duty. ________________________________________ ________________________ Signature of Permittee or Designated Agent Date ________________________________________ Printed name and title of signatory Note: Certificate of Insurance in the amount of $500,000 and a copy of state permit is required to accompany application or permit bond if required.    0UX     : V m s u { O R   }  ļ懼ļ|hG>*CJOJQJhD] OJQJhD] CJOJQJ&jhGCJOJQJUmHnHuhbhbCJOJQJaJhbOJQJh7OJQJhGCJOJQJhGCJOJQJ hGCJ hGCJOJQJhCOJQJhGOJQJ0 0VWX     : T   @  1$gdD]  @  1$$1$a$1$$1$a$d O P Q R   ~  B C klm `1$$1$a$1$ k="`adeƣhGhG5CJOJQJhb5CJOJQJhG5CJOJQJhh|lr5 hh|lrh|lr h|lr5h|lrOJQJhD] OJQJ hGCJhGCJOJQJ hG5CJhG>*CJOJQJhGOJQJ89"SgdH ^`gdH$a$gdH !1$ P1$ 1$1$ B(w%&#$1$#$rsYZKLgdH!jkabcde$ a$1$gdH : 00P/ =!8"8#`$`%0 %: 00P/ =!8"8#8$8%0 %D 00P/ =!8"8#8$8%0 %6A: 00P/ =!8"8#8$8%0 %D 00P/ =!8"8#8$8%0 %: 00P/ =!8"8#8$8%0 %: 00P/ =!8"8#8$8%0 %D 00P/ =!8"8#8$8%0 %#: 00P/ =!8"8#8$8%0 %8@8 Normal_HmH sH tH D@D Heading 1 $1$@& CJOJQJN@N Heading 2$$1$@&a$5CJOJQJDA@D Default Paragraph FontViV  Table Normal :V 44 la (k(No List DB@D Body Text $1$a$ CJOJQJBP@B Body Text 21$ CJOJQJeXPme,<,x,,,@-|--- 0VWX:TOPQR~BCklm89   " S  # $ r s YZKL!jkabcf000000000000000000000000000000000000000000000000000000000000000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@000000x e ed8@(  \  3 jJ" B S  ?eHx%Htt\l \Dh,*L, lEl,<r ?< d!"w #l$*urn:schemas-microsoft-com:office:smarttags PostalCode;*urn:schemas-microsoft-com:office:smarttagsaddress9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsCity RDff3 UU  #66UU``efhkmmrr{   "   # s YZ!ffD] C|lrG7H|Mb@\\chinfo\CA2300BNe03:winspoolHP LaserJet 2300 Series PCL 6\\chinfo\CA2300BC odXXLetter DINU"L$SMTJHP LaserJet 2300 Series PCL 6InputBinFORMSOURCERESDLLUniresDLLResolution600dpiFastResTrueOrientationPORTRAITHPOrientRotate180FalseCollateONEconomodeFalseTTAsBitmapsSettingTTModeOutlineRETChoiceTrueHPStraightPaperPathFalseHPPrintOnBothSidesManuallyFalseHPManualDuplexDialogItemsInstructionID_01_NPPHPManualFeedOrientationFACEDOWNHPOutputBinOrientationFACEDOWNHPManualDuplexDialogModelModelessHPManualDuplexPageOrderEvenPagesFirstHPMapManualFeedToTray1TrueJRHDNotInstalledJRHDOffPrintQualityGroupPQGroup_3HPLpiSelectionNoneJRConstraintsJRCHDPartialJRCmdCallbackJRHPColorModeMONOCHROME_MODEHPPDLTypePDL_PCL6HPPJLEncodingUTF8HPJobAccountingHPJOBACCT_JOBACNTHPBornOnDateHPBODHPJobByJobOverrideJBJOHPPCL6PassThroughTrueHPFontInstallerTRUEDuplexNONEPaperSizeLETTERHPPaperSizeDuplexConstraints16KMediaTypeAutoHPXMLFileUsedHPXMLFileNameIUPHdLetter [none] [none]Arial4Pd?LDALE<Automatic>0    j i k k m m \\chinfo\CA2300BC odXXLetter DINU"L$SMTJHP LaserJet 2300 Series PCL 6InputBinFORMSOURCERESDLLUniresDLLResolution600dpiFastResTrueOrientationPORTRAITHPOrientRotate180FalseCollateONEconomodeFalseTTAsBitmapsSettingTTModeOutlineRETChoiceTrueHPStraightPaperPathFalseHPPrintOnBothSidesManuallyFalseHPManualDuplexDialogItemsInstructionID_01_NPPHPManualFeedOrientationFACEDOWNHPOutputBinOrientationFACEDOWNHPManualDuplexDialogModelModelessHPManualDuplexPageOrderEvenPagesFirstHPMapManualFeedToTray1TrueJRHDNotInstalledJRHDOffPrintQualityGroupPQGroup_3HPLpiSelectionNoneJRConstraintsJRCHDPartialJRCmdCallbackJRHPColorModeMONOCHROME_MODEHPPDLTypePDL_PCL6HPPJLEncodingUTF8HPJobAccountingHPJOBACCT_JOBACNTHPBornOnDateHPBODHPJobByJobOverrideJBJOHPPCL6PassThroughTrueHPFontInstallerTRUEDuplexNONEPaperSizeLETTERHPPaperSizeDuplexConstraints16KMediaTypeAutoHPXMLFileUsedHPXMLFileNameIUPHdLetter [none] [none]Arial4Pd?LDALE<Automatic>0    j i k k m m DeP@UnknownGz Times New Roman5Symbol3& z Arial3TimesK,Bookman Old Style"hfff " "!24d2QHX(?72APPENDIX A - APPLICATION FORMLynn E. AllsbrookldaleOh+'0 ,8 X d p | APPENDIX A - APPLICATION FORMLynn E. Allsbrook Normal.dotldale3Microsoft Office Word@G@A@p@_՜.+,0 hp|   " ' APPENDIX A - APPLICATION FORM Title !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGIJKLMNOQRSTUVWZRoot Entry F`\Data 1Table NWordDocument:.SummaryInformation(HDocumentSummaryInformation8PCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q