License Application Form

Explanation of Fees Due

Administrative Fee - $1,000 to be submitted with application
License Fee - Minimum annual fee of $1,000 for standard licenses and $5000 for telecommunication and utility licenses. To be paid at the time of license execution.
Design and Construction Review Fee - This fee is not required for all applications. If you are required to pay this fee you will be contacted by the MRG Director of Licensing - $1,600 + Structural Review Fee (to be determined by MBTA)

All checks should be made payable to the MBTA and submitted to:
Greystone
Attention: Brian Clarizia
20 Park Plaza, Suite 1120
Boston, MA 02116

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 billing address indicated below.

Massachusetts Bay Transportation Authority- Application for Entry Upon MBTA Railroad, Transit or Other Property

* Indicates a required field

Contact/Company Information

Applicant Name*

Title

Company Name*

Legal Address 1*

Legal Address 2

City*

State*

Zip*

Phone*

Email*

Business Type

State of Incorporation

Billing Information

Check box if same as above; if not, please complete below

Billing Address 1*

Billing Address 2

Department/ATTN:

City*

State*

Zip*

Phone*

Email*

General Information

1) Proposed License Commencement Date*

2) Anticipated length of project*

3) Agents for applicant for service of notice

4) Is applicant self-insured? If yes, attach copies of authorizing legislation or certification thereof

a) If yes, what are the limits of self-insurance?

5) If applicant is authorized by public authority to enter into such license agreement, please provide:

a) Motion, Resolution, or Ordinance #

b) Date of adoption

c) Adopted by

6) 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?

7) Applicant's officer authorized to sign agreement:

a) Name

b) Title

c) Email

8) Does your project request trigger approval under the Massachusetts Environmental Policy Act (MEPA)?*

a) Please attach your MEPA certificate at the end of this form or provide your MEPA number.

Project Description

1) Specific description of proposed construction location, i.e. Property Address, Crossing, Right of Way*

2) Brief description of purpose of entry and/or installation (including types of pipes and other attachments or ancillary facilities to be installed on MBTA Railroad Property)*

Space Requirements

Please submit (using one of the methods mentioned above) 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?

2) If occupancy is under, over, through, or attached to undergrade or overhead bridge, who owns?

3) Type of Occupancy (Facility)

A. Size

1. Exact length of MBTA property to be burdened by occupancy

2. Width of excavation facility on MBTA railroad property

3. Number of manholes

B. Does this project involve the installation of aerial or underground wire and cables?

1. Does this project involve the installation of telephone or other communication cables?

a) Number of cables

b) Number of pairs/cable

c) Are these composite coaxial cables?

2. Does this project involve the installation of power cables?

a) Number of cables/size

b) Number of volts per conductor

c) Are these pipe-type cables consisting of one or more high voltage cables encased in steel pipe under inert oil pressure?

3. Does this project involve the installation of fiber optic cables?

a) Number of cables

b) Number of distribution cables

c) Number of transmission cables

d) Number of strands in each cable

e) Number of repeater stations on MBTA Railroad property

f) Systems (check one)

Transmission
Distribution
Sensor

4. Number of spare or unoccupied ducts to be installed

5. Does this project involve the installation of attachments of aerial wires and cables to poles or other structures of MBTA used in wire line construction or support?

a) Number of wires attached to MBTA cross-arm

b) Voltage of wire

c) Number of wires attached to applicant's cross-arm or bracket

d) Voltage of wire

e) Number of cross-arms or brackets attached to MBTA poles

6. Does this project involve the installation of aerial wires and cables to building or structures other than those used in wire line construction or support?

a) Number of wires attached to MBTA's building or structures

7. Does this project involve the installation of attachments of cable terminals to poles, buildings, or structures including highway bridges, railroad bridges over highways, or other bridges of MBTA?

a) Number of cable terminals, loading coils, transformers, or like devices attached

b) Explain

8. Does this project involve the installation of guy wire crossings and overhanging cross-arms and power wires of pole lines outside MBTA right-of-way?

a) Number of guy wires crossing MBTA Railroad property but not anchored thereon

b) Number of cross-arms overhanging MBTA Railroad Property from poles located outside thereof

c) Number of cross-arms on any poles

C. Does this project involve the installation of pipes and/or sewers?

1. Does this project involve the installation of circular line pipes carrying no pressure?

a) Number of pipes

b) Number of inches inside nominal diameter per pipe

2. Does this project involve the installation of circular line pipes under pressure and carrying non-flammable, non-explosive, or non-combustible supporting materials (except coal and slurry)?

a) Number of pipes

b) Number of inches inside nominal diameter per pipe

3. Does this project involve the installation of circular line pipes under pressure and carrying flammable, explosive, or combustible supporting materials?

a) Number of pipes

b) Number of inches inside nominal diameter per pipe

4. Does this project involve the installation of non- circular pipes?

a) Number of pipes

5. Will a pipe be constructed?

6. Will pipe structure be supported by MBTA structures, bridges, etc.?

Explain

7. Will pipe structure be attached to MBTA structures, bridges, etc.?

Explain

D. Does this project involve the installation of poles and/or supporting structures?

1. Number of wooden poles to be installed on MBTA railroad property

2. Does this project involve the installation of other wooden supporting structures?

a) Number of supporting structures

3. Does this project involve the installation of steel supporting structures?

Explain

4. Number of braces, stub poles

5. Number of guy wires anchored on MBTA Railroad property

6. Number of span guy wires crossing MBTA Railroad property

Certifications

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 believe, have (has) filed all state tax returns and paid all state taxes required by law.

Federal Identification Number

By

Date

Employer's Certificate of Compliance with Massachusetts Employment Security Law

Pursuant to G.L.C. 151 A, Sec 19A(b), I __________ on behalf of (Name of Employer) ________________ , certify under the penalties of perjury that the aforementioned employer has complied with all laws of the Commonwealth relating to contributions and payments in lieu of contributions.

Signed under the penalties of perjury this ______ day of __________________, 20__.

Name (Printed)

Name of Employer

Date

Statement Regarding Beneficial Interests

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.

Date

Applicant

Building Site

Building Address

Please list names and address of all persons who have or will have direct or indirect beneficial interest below:

Acknowledgement

PLEASE ACKNOWLEDGE YOUR ELECTRONIC SIGNATURE BY CHECKING THE BOX BELOW AND CLICK TO SUBMIT THE APPLICATION TO GREYSTONE. PLANS AND FEE SHOULD BE SUBMITTED TO GREYSTONE VIA US MAIL.

I certify that all the information provided above is correct *

Attach Files (Optional)

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