Maine Department of Transportation

Highway Opening Application

Applicant Information:	Date:
Name:	Phone:	Pager/Cell:
Address:	Town:	State:	ZIP:
Primary Contact Information: (Write “SAME” if the primary contact for on-site work will be the Applicant)
Name:	Phone:	Pager/Cell:
Address:	Town:	State:	ZIP:
Proposed Work Information:	Highway Number (if known):
Town:	Road Name:
Type of Work Proposed:	*Please attach a sketch plan*
Who will perform the work?
Anticipated work schedule:	Starting Date:	Completion Date:
If this work is for a utility, has an application for a Utility Location Permit been submitted? Yes No N/A
Is this work intended to be performed under the Funding Agency Addendum requirements? Yes No N/A
Have all existing utilities in the work area been notified of the proposed work and given an opportunity to comment? Yes No
GPS Coordinates of Work Location: (Please enter coordinates in Decimal Degrees, WGS 1984)
Latitude (ex: 44.3074199)	Longitude (ex: -69.7775613)
Starting Point:
Ending Point:

Impact & Fee Information:
Surface Type:	(A) Unit Cost:	(B) Estimated Area	Impact Value (A)x(B)
Paved Surface: Bituminous Concrete or treated surface/shoulders (Min. fee $50, see below)	$50.00 per Sq. Yard	Sq. Yard(s)	$
Concrete Surface: Portland Cement Concrete or Bituminous on concrete. (Min. fee $75, see below)	$75 per Sq. Yard	Sq. Yard(s)	$
All Other Surfaces: Plain gravel surface or shoulder or area outside roadbed. (Min. fee $25, see below)	$5.00 per Sq. Yard	Sq. Yard(s)	$
Direct Buried Cable: (Low-impact installation of cable outside of the traveled way/shoulder)	$0.20 per Lineal Foot	Lineal Feet	$
Other Work in addition to replacing pavement (Specify)	$
Total Impact Value (Sum of all Impact Values)	$
Permit Fee (10% of Total Impact Value, OR, if the calculated Permit Fee is less than the highest minimum fee specified above for the surface type impacted, than the highest applicable minimum fee shall be used. (Example: if you impact a paved and a non-paved surface, the applicable minimum fee is $50).	$
Instructions for Payment:
If you are a licensed utility, a municipality or any other governmental entity AND the TOTAL IMPACT VALUE calculated above is $5,000 or less, please include payment in the amount of the Permit Fee with this application, made out to Treasurer, State of Maine.
If you are NOT a licensed utility, a municipality or any other governmental entity, AND the TOTAL IMPACT VALUE calculated above is $2,500 or less, AND you will not be impacting the paved or concrete surface of the highway, please include payment in the amount of the Permit Fee with this application. If you ARE proposing to impact the paved or concrete surface of the highway, please include payment in the amount of the TOTAL IMPACT VALUE and all but 10% will be returned to you upon satisfactory completion of the work.
If the TOTAL IMPACT VALUE exceeds $5,000 for licensed utilities, municipalities or other governmental entities, OR $2,500 for all other applicants, a SPECIAL OPENING PERMIT as described in section II E of the Rules, Regulations and Policies shall also apply. In this circumstance, an escrow account will be established and there is no direct payment submitted with this application. Do you request refund of the entire permit fee contingent on a full width overlay per Section II, A. of the Special Opening Permits?

NOTICE TO APPLICANT: the Applicant is hereby notified that, upon approval of this application, all work shall comply with the following requirements, as applicable: (1) all conditions specified in the Highway Opening Permit; (2) the Department’s Highway Opening Rules, Regulations and Policies; (3) the Department’s Utility Accommodation Rule (17-229 CMR 210); (4) all conditions of a Utility Location Permit issued pursuant to 17-229 CMR 210; and (5) local ordinances and federal and state laws. In the event of a conflict between any applicable requirements, the more stringent requirement shall govern unless otherwise directed by the Department. Specific attention is directed to the following requirements: (1) Work zone traffic control standards as defined by the Manual on Uniform Traffic Control Devices (MUTCD); (2) Occupational Safety & Health Administration (OSHA) trenching and excavation standards; and (3) 23 MRSA Section 3360-A, Protection of Underground Facilities (a.k.a. “The Dig Safe® Law”) which requires notification to various entities at least three working days prior to making any excavation. Additional information may be found at: http://mutcd.fhwa.dot.gov , http://www.osha.gov/SLTC/trenchingexcavation/ , and www.digsafe.com respectively. The applicant further agrees that, upon approval and issuance of a permit, the Department will be notified at least 48 hours in advance of the start of any work. The Applicant shall be responsible for all final restoration of the affected area to the satisfaction of the Department of Transportation.

Applicant’s Signature: ______________________________________	Date: ________________________	Version 0721

Highway Opening Application Sketch Plan

Applicant Name:	Town:

The purpose of this "Sketch Plan" is to show the location of the proposed opening in relation to the highway. This plan is not intended to be drawn to scale, however, you must accurately reference the proposed facility and excavation with offset distances from one of the lines on the road. In addition, please provide other accurate dimensions as necessary.

Indicate NORTH