MASSACHUSETTS BAY TRANSPORTATION AUTHORITY APPLICATION FOR ENTRY UPON MBTA RAILROAD, TRANSIT, OR OTHER PROPERTY
General
Date of Application
1a. Name of Applicant:  
1b. Company or Entity Name:  
2. Type of Entity (Partnership, Corporation, Proprietorship, Public Authority, etc.):  
3. Mailing Address:  
4. Applicant's Phone Number:  
5. Applicant's Email:    
6. If incorporated, state of incorporation:
7. Agents for applicant for service of notice or process:
8. If applicant is self-insured, please provide limits of self-insurance and copies of authorizing legislation or certification thereof:
9. If applicant is authorized by public authority to enter into such license agreement, please provide:
a) Motion, Resolution, or Ordinance No.:
b) Date of Adoption:
c) Adopted By:
10. Is the applicant seeking permission to perform environmental testing and/or assessment on Authority property?
a) Is the proposed testing and/or assessment required by the Massachusetts Contingency Plan (“MCP”)?
b) What is the Release Tracking number and current status of the MCP work?
Name and title of applicant’s officer authorized to sign agreement:
Project Description
1. Brief description of construction (including types of pipes and other attachments or ancillary facilities to be installed on MBTA Railroad Property):
2. Brief description of purpose of entry and/or installation:
Space Requirements
Please submit with your signed application a plan indicating requirements for the size and configuration of the proposed license area, using as many location indicators, such as railroad mileposts or other benchmarks as possible.
An example is show below.
Technical Information
1. Is this occupancy within the limits of a public road?
Please submit copies of applicant’s franchise to occupy such space.
2. If occupancy is under, over, through, or attached to undergrade or overhead bridge, who owns such bridge?
3. Type of occupancy (facility):
a) Exact Length of MBTA Railroad Property to be burdened by occupancy:
b) Width of excavation facility on MBTA Railroad Property:
c) Number of manholes:
   
A. Aerial or underground wire and cable:
(1) Telephone and other communication cables:
Number of cables:
Number of pairs/cable:
Are these composite coaxial cables?
(2) Power Cables:
Number of cables/size:
Number of volts per conductor:
Are these pipe-type cables consisting of one or more high voltage cables encased in steel pipe under inert oil pressure?
(3) Fiber optic cables:
Number of cables:
Number of distribution cables:
Number of transmission cables:
Number of strands in each cable:
Number of repeater stations on MBTA Railroad Property:
Systems (check one):
Transmission:
Distribution:
Sensor:
(4) Number of spare or unoccupied ducts to be installed:
   
B. Pipes and Sewers:
(1) Circular line carrying no pressure:
Number of pipes:
Number of inches of inside nominal diameter per pipe:
(2) Circular lines under pressure and carrying non-flammable, non-explosive, or non-combustible supporting materials, except coal and slurry:
Number of pipes:
Number of inches of inside nominal diameter per pipe:
(3) Circular lines under pressure and carrying flammable, explosive, or combustible supporting material:
Number of pipes:
Number of inches of inside nominal diameter per pipe:
(4) Non-circular pipe:
(5) Will a pipe tunnel be constructed?
(6) Will pipe be supported by MBTA structures, bridges, etc.?
Explain:
(7) Will pipe be attached to MBTA structures, bridges, etc.?
Explain:
   
C. Ancillary Facilities:
Number of wooden poles to be installed on MBTA Railroad Property:
Other wooden supporting structures:
Steel supporting structures:
Explain:
Number of braces, stub poles:
Number of guy wires anchored on MBTA Railroad Property:
Number of span guy wires crossing MBTA Railroad Property:
   
D. Attachments:
(1) Attachment of aerial wires and cables to poles or other structures of MBTA used in wire line construction or support:
Number of wires attached to MBTA cross-arm:
Voltage of wire:
Number of wires attached to applicant’s cross-arm or bracket:
Voltage of wire:
Number of cross-arms or brackets attached to MBTA poles:
(2) Attachment of aerial wires and cables to building or structures other than those used in wire line construction or support:
Number of wires or cables attached to MBTA’s building or structures:
(3) Attachment of cable terminals to poles, buildings, or structures including highway bridges, railroad bridges over highways, or other bridges of MBTA:
Number of cable terminals, loading coils, transformers, or like devices attached:
Explain:
   
E. Guy wire crossings and overhanging cross-arms and power wires of pole lines outside MBTA right-of-way:
Number of guy wires crossing MBTA Railroad property but not anchored thereon:
Number of cross-arms overhanging MBTA Railroad Property from poles located outside thereof:
Number of cross-arms on any poles:
   
   
It is hereby understood and agreed that the undersigned applicant will bear any and all costs associated with MBTA’s preliminary and final engineering review in connection with this application. Any charges in excess of the initial advance payment will be billed directly to the address indicated in Item #3 above.
PLEASE ACKNOWLEDGE YOUR ELECTRONIC SIGNATURE BY CHECKING THE BOX BELOW AND CLICK TO SUBMIT THE APPLICATION TO TRA. PLANS AND FEE SHOULD BE SUBMITTED TO TRA VIA US MAIL.
For(Name of Applicant):
By(Title):
Date:
   
REVENUE ENFORCEMENT AND PROTECTION PROGRAM CERTIFICATION
Pursuant to M.G.L. Ch. 62C, Sec. 49A, I certify under penalties of perjury that I (my company), to my best knowledge and belief, have (has) filed all state tax returns and paid all state taxes required under law.
Social Security Number or Signature of Individual or Corporate Name Federal Identification Number:
By:
Corporate Officer (If applicable)
Date:
   
   
EMPLOYER’S CERTIFICATE OF COMPLIANCE WITH MASSACHUSETTS EMPLOYMENT SECURITY LAW
Pursuant to G. L. C. 151A, Sec. 19A(b), I  on behalf of (Name of Employer)  D.E.T. ID Number , certify under the penalties of perjury that the aforementioned employer has complied with all laws of the Commonwealth relating to contributions and payments is lieu of contributions.

Signed under the penalties of perjury this    day of , 20 

Name of Employer

Name

Title
   
   
The employer may certify its compliance if it has entered into and is complying with a repayment agreement satisfactory to the Commissioner or there is a pending adjudicatory proceeding or court action contesting the amount due pursuant to G. L. C. 161A, Sec. 19A(c).
STATEMENT REGARDING BENEFICIAL INTEREST
In compliance with the provisions of Chapter 7, Sec. 40J of the General Laws, I hereby state, under the penalties of perjury, that the true names and addresses of all persons who have or will have a direct or indirect beneficial interest in the real property subject to this Application dated , 20, between as applicant/tenant, for premises in the building (on the site) know as , and located at are listed below.
Name and residence of all persons with beneficial interests:
1.
2.
3.
4.
5.
6.
Title
   
Date