Form M-4902 - Application/permit To Exceed Posted Weight Or Size Limit

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M-4902 (3-12)
PERMIT NO.
APPLICATION/PERMIT TO EXCEED POSTED
WEIGHT OR SIZE LIMIT
PLEASE TYPE OR PRINT ALL INFORMATION IN bLuE OR bLAck INk
www dot state pa us
PHONE
Application is
NAME OF APPLICANT/OWNER
hereby made by
CITY
STATE
ZIP CODE
Address of
STREET
Applicant/Owner
o
o
o Weight Limit
o Size Restriction
This application is to exceed a posted (check one or both, as applicable)
o
o
o highway
o bridge; in _________________________________________________ County, PA.
on a (check one only)
The posted restriction is __________________________________________________________________________________________
(include units such as tons, feet, inches, etc.)
and is located at or between __________________________________________ on State Route # ______________________________
(also indicate on an attached map)
This application is for _________________ of trip(s). Move begins _________________ Move ends _________________ Fee _________
(number)
(date)
(date)
GROSS WEIGHT
(Lbs.)
TYPE _______________________________________________________
REGISTERED
(Lbs.)
LOAD_______________________________________________________
GROSS WEIGHT
Load Description
TOTAL LENGTH
(Feet)
(Inches)
EQUIP./AXLES ______________________________________________
Equipment Description/Number of Axles per Vehicle
TOTAL WIDTH
(Feet)
(Inches)
TRUCK LICENSE/ST. __________________________________________
License Number
State of Registration
TOTAL HEIGHT
(Feet)
(Inches)
TRAILER LICENSE/ST. ________________________________________
License Number
State of Registration
THIS SECTION TO BE COMPLETED FOR BRIDGES ONLY
Axle Number
Axle Weight Due
Total Axle Weight
Manufacturer’s
Distance From
Width of Axle
Number
Pneumatic
Vehicle Registration
(front to
to Vehicle Only
Due to Vehicle and
Rated Axle
Previous Axle
(center to center
of Tires
Tire Width
Number or
back)
(pounds)
Load (pounds)
Capacity
wheel or group)
VIN Number
1
2
3
4
5
6
7
Totals
All load-bearing wheels in a straight transverse line constitute an axle.
POLICY NO.(S)
INSURANCE CO. NAME
PUBLIC LIABILITY
PROPERTY DAMAGE
EFFECTIVE PERIOD(S)
$
$
I, the undersigned, hereby certify that the data submitted is correct to the best of my knowledge and belief.
Signature
X
& Title
DATE _____________________________________
INSTRUCTIONS
Complete all above sections of this form and submit with a check or money order made payable to the Pennsylvania Department of Transportation, in the amount determined by the De-
partment. Submit a separate application for each posted highway section (including bridges thereon), for each separately posted bridge and for each vehicle or combination. Justification
for the permit should also be provided. Upon review of this application, the Department may approve the request by issuing the permit below.
Applicant – Do Not Write Below This Line
PERMIT TO EXCEED POSTED WEIGHT OR SIZE LIMIT
The above application is approved subject to Section 4902 of the “Vehicle Code”, and all appropriate Department Regulations (in particular, 67 Pa. Code-Chapters 189, 191 or 193) and
subject to any special conditions or restrictions set forth herein or attached hereto. This permit does not authorize the permitted vehicle to exceed any maximum size or weight limit.
This application/permit shall be carried in the permitted vehicle while traveling upon the highway or bridge specified above (except Type 2 permits which authorize use of a particular
posted highway or portion thereof by any number of over-posted-weight vehicles being driven to or from a common destination.)
Permit Issuance Date: _________________________________________________ By District Executive: _____________________________________________________________
Permit Expiration Date: _________________________________________________ For: __________________________________________________________________________
Secretary of Transportation

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