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TYPE PERMIT REQUESTED: Single Trip Single Trip & Return Annual Seasonal ________months Emergency Preliminary Superload Final Superload _______ of _______PERMIT office ________________________________ NAME ________________________________________ ________________________________ACCOUNT NO. _________________________________ STREET ________________________________________ ______________________________FEIN/SSN _____________________________________ CITY-STATE-ZIP CODE ________________________________________ __________________BILL CODE ___________________________________ PERMIT FEE GROSS WEIGHT __________________(lbs.) LEGAL WEIGHT __________________(lbs.) TOTAL LENGTH __________(ft.) ______ (in.)TOTAL WIDTH ________ (ft.) ______ (in.) BODY WIDTH (63A/63B) ___________(ft.) _______ (in.) TOTAL HEIGHT __________(ft.) ______ (in.)LOAD _____________ _____________________________________ _________________ ________________________________________ __VEHICLE # EQUIPMENT TYPE (List Power & Drawn Units)US DOT # PLATE#/VIN # STATE # AXLES123TOTAL AXLE WEIGHTS ________________________________________ ________________________________________ __________________________AXLE DISTANCES (Ft.)

Office of Chief Counsel, 400 North Street, 9th Floor, Harrisburg, Pennsylvania 17120-0096. A filing fee as prescribed under Chapter 491,made payable to the ''Commonwealth of Pennsylvania,'' shall accompany each request.

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