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Single Trip Permit Application: Section A - Customer Please Print Clearly or Type

This document is a single trip permit application for transporting a mobile home or modular building section in Wisconsin. It collects information about the customer, load details including dimensions, vehicle details, insurance coverage, origin and destination of the trip, and requires acceptance of permit conditions. Single trip permits through this application may be issued only by the Wisconsin Department of Transportation for travel on all state highways, local and county roads, and are valid for two weeks.

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Julian Tremont
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132 views1 page

Single Trip Permit Application: Section A - Customer Please Print Clearly or Type

This document is a single trip permit application for transporting a mobile home or modular building section in Wisconsin. It collects information about the customer, load details including dimensions, vehicle details, insurance coverage, origin and destination of the trip, and requires acceptance of permit conditions. Single trip permits through this application may be issued only by the Wisconsin Department of Transportation for travel on all state highways, local and county roads, and are valid for two weeks.

Uploaded by

Julian Tremont
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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SINGLE TRIP PERMIT APPLICATION Original Trip Log No.-For Dept.

/Commercial Permit Service Use ONLY


to transport a mobile home and / or modular building section Return Trip
MV2601 7/2004 s.348.26(4) Wis. Stats. Cancellation Mail To: Wisconsin Department of Transportation Permit Unit
http://wisconsindot.gov/Pages/dmv/com-drv-vehs/mtr-car-trkr/osowgeneral.aspx P. O. Box 7980
Madison, WI 53707-7980
Section A - Customer Please print clearly or type. Telephone: 608-266-7320
1. Permit Customer No. - If Available Desired Effective Date
PC - Valid for two (2) weeks
2. Legal Name - Vehicle Owner or Lessee Doing Business As (D/B/A)

Mailing Address Federal Employer Identification No. Social Security No. (Optional)

City State Zip Code U.S. DOT Number WI Account No.

(Area Code) Business Telephone No. County 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 Year Make Axles Unit
__ Truck
Towed Vehicle - Mobile Home Serial Number State Year Make

Modular Building Section License or Vehicle Identification No.


Towed On
Dollies
Undercarriage
Other:
Section D Size Length Width Height
Feet Inches Feet Inches Feet Inches
Roof

Towed Vehicle below Roof

Overall

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, Group B Permitted dimensions: Dimensions exceeding Group A
13 1/2 ft. high, 100 ft. long, 125% of statutory GVW
Level Required: Combined Single Limit $750,000 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 Via Highways - continued

If return trip is requested, are the return dimensions and route (in reverse direction) the same as the "Original Trip"?
Return ____ Yes
Trip ____ 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 Acceptance of Conditions: I, the customer or authorized agent, certify
that the statements contained in the application are true and correct, and if
Permit Number granted a permit, I will comply with all terms and conditions that apply.
Revised / Amended Permit Number
X
(Customer or Authorized Agent) (Date)

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