Free Single Trip Permit Application - Wisconsin

SINGLE TRIP PERMIT APPLICATION
to transport a mobile home and / or modular building section MV2601 7/2004 s.348.26(4) Wis. Stats. www.dot.wisconsin.gov/business/carriers/osowgeneral.htm

Section A - Customer

Please print clearly or type.

1. Permit Customer No. - If Available PC 2. Legal Name - Vehicle Owner or Lessee Mailing Address City (Area Code) Business Telephone No. State Zip Code County

Mail To: Wisconsin Department of Transportation Permit Unit P. O. Box 7980 Madison, WI 53707-7980 Clear Form Telephone: 608-266-7320 Desired Effective Date Valid for two (2) weeks Doing Business As (D/B/A) Federal Employer Identification No. U.S. DOT Number Social Security No. (Optional) WI Account No.

Original Trip Return Trip Cancellation

Log No.-For Dept./Commercial Permit Service Use ONLY

Contact Name for DOT to call if questions / (Area Code) Telephone No.

Section B - Load
Mobile Home Modular Building Section Serial No.:

Section C - Vehicles Power Unit - Both Plate/State and VIN must be identified - Drive axle must have dual wheels.
Plate State Vehicle Identification No. (VIN) __ Truck-tractor __ Truck State Year Make Axles Unit

Towed Vehicle - Mobile Home Serial Number

Year

Make

Modular Building Section Towed On Dollies Undercarriage Other:

License or Vehicle Identification No.

Section D Size
Roof Towed Vehicle below Roof Overall

Length Inches Feet

Feet

Width Inches

Height Feet Inches

Section E Insurance - The customer has the insurance coverage indicated in full force and effect. Check Group A or Group B.

Group A Permitted dimensions cannot exceed: 12 ft. wide,
13 1/2 ft. high, 100 ft. long, 125% of statutory GVW Level Required: Combined Single Limit $750,000

Group B Permitted dimensions: Dimensions exceeding Group A
Level Required: Combined Single Limit $1,000,000

Section F - Axle Weight / Spacing - Not applicable to this form Section G - Trip
From City, Village, Township To City, Village Township Via Highways

Original Trip Return Trip

Via Highways - continued If return trip is requested, are the return dimensions and route (in reverse direction) the same as the "Original Trip"? ____ Yes ____ No, On a second application, check Return Trip box at top, complete Section A Items 1 and 2, and Sections D, E, and G.

NOTE: Single trip permits for mobile homes and/or modular building sections may be issued only by the Wisconsin Department of Transportation's Madison Office, and are valid on all state highways, local and county roads. FOR DEPT USE ONLY Permit Number Revised / Amended Permit Number Acceptance of Conditions: I, the customer or authorized agent, certify that the statements contained in the application are true and correct, and if granted a permit, I will comply with all terms and conditions that apply.

X
(Customer or Authorized Agent) (Date)