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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
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
Phone
*
Email
*
Business Type
Corporation
Municipality
Limited Liability Corporation
Limited Liability Partnership
Limited Partnership
General Partnership
Other
State of Incorporation
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Billing Information
Check box if same as above; if not, please complete below
Billing Address 1
*
Billing Address 2
Department/ATTN:
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
Phone
*
Email
*
General Information
1) Proposed License Commencement Date
*
MM slash DD slash YYYY
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
Yes
No
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
MM slash DD slash YYYY
c) Adopted by
6) Is the applicant seeking permission to perform environmental testing and/or assessment on Authority property?
Yes
No
a) Is the proposed testing and/or assessment required by the Massachusetts Contingency Plan (“MCP”)?
Yes
No
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)?
*
Yes
No
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?
Yes
No
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?
Yes
No
1. Does this project involve the installation of telephone or other communication cables?
Yes
No
a) Number of cables
b) Number of pairs/cable
c) Are these composite coaxial cables?
Yes
No
2. Does this project involve the installation of power cables?
Yes
No
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?
Yes
No
3. Does this project involve the installation of fiber optic cables?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
1. Does this project involve the installation of circular line pipes carrying no pressure?
Yes
No
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)?
Yes
No
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?
Yes
No
a) Number of pipes
b) Number of inches inside nominal diameter per pipe
4. Does this project involve the installation of non- circular pipes?
Yes
No
a) Number of pipes
5. Will a pipe be constructed?
Yes
No
6. Will pipe structure be supported by MBTA structures, bridges, etc.?
Yes
No
Explain
7. Will pipe structure be attached to MBTA structures, bridges, etc.?
Yes
No
Explain
D. Does this project involve the installation of poles and/or supporting structures?
Yes
No
1. Number of wooden poles to be installed on MBTA railroad property
2. Does this project involve the installation of other wooden supporting structures?
Yes
No
a) Number of supporting structures
3. Does this project involve the installation of steel supporting structures?
Yes
No
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
MM slash DD slash YYYY
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
MM slash DD slash YYYY
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
MM slash DD slash YYYY
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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