New Permit Application continued ... page 4

Office Use Only
Application number
Payment reference
Urgent requirement / Yes No
Date permit required

1. Application information

Excess Mass/Dimension Permit type / Classification type / Delivery method
Mass / Period / Pick up
Dimension Permit * / Single trip / Mail
Mass & Dimension Permit * / Special assessment / Fax (not available for Period Mass Permit & LONO)
*Building movement: Yes No (Single Trip & Special Assessment Only)

2. Operator information

Name of applicant

Trading name (for organisations); or Full name (for individuals)
Approved Heavy Haulage Operator (AHHO) number (if available)
AHHO number

Approved Heavy Haulage Operator (AHHO) number (not available)

Customer Reference Number (CRN) / Australian Company Number (ACN)
Business address
Contact person / Phone number
Mobile number / Fax number

3. Vehicle information

Vehicle details

Rego number / State / Rego number / State
VIN or Chassis number / VIN or Chassis number

Authority to Operate (ATO) number (if available) Exempt Authority to Operate

ATO number / Exemption number

Authority to Operate (ATO) number (not available)

Make/Model / Engine number
Registered Operator / Vehicle type

Trailing groups (Prime movers only) (Required for all Excess Mass related permits)

Trailing group /
Number of axles
/
Tyres per axle
Dolly/Single axle / Yes No / One
Dolly/Tandem axle / Yes No / 2
Semi trailer or Low loader/ Tandem axle / Yes No / 2
Semi trailer or Low loader/ Tri axle / Yes No / 3
Semi trailer or Low loader/ Quad axle / Yes No / 4
Special combination / Yes No
Special purpose trailer
Advise ATO number / Yes No
Platform/s
Number of separate platforms / Yes No

4. Travel information

Period Mass Permit/LONO

Proposed date

Start date / End date / (note: Not to exceed 3 months)

Proposed centre of area of operation (Period)

Note: Operation in more than 2 Regions requires special assessment, if requested attach a full explanation of requirement.

Location / Location / Location
Southern QLD Region / South East Qld Region / North QLD Region
Bundaberg / 150km / Brisbane / 150km / Bowen / 300km
Charleville / 300km / Gympie / 150km / 150km
150km / Nerang / 150km / Cairns / 300km
Dalby / 150km / Central Qld Region / 150km
Eromanga / 300km / Bedourie / 300km / Charters Towers / 300km
150km / 150km / 150km
Goondiwindi / 220km / Blackwater / 300km / Cloncurry / 300km
Maryborough / 150km / 150km / 150km
Miles / 220km / Emerald / 300km / Cooktown / 300km
Roma / 300km / 150km / 150km
150km / Gladstone / 150km / Hughenden / 300km
St George / 300km / Longreach / 300km / 150km
150km / 150km / Ingham / 150km
Toowoomba / 150km / Mackay / 150km / Normanton / 300km
Warwick / 150km / Moura / 150km / 150km
Rockhampton / 150km / Townsville / 150km
Tambo / 300km / Weipa / 300km
150km / 150km

Proposed other routes (Period)

(All proposed state controlled roads MUST be listed)

Start location / End location / Requested route (include road numbers if available)

Single Trip Mass Permit / LONO or Special Assessment Mass Permit / LONO

Proposed date and time

Start date / End date / (note: Not to exceed 14 days)
Start time# / End time#

Proposed start and end location (Single trip)

Start location / End location
Start address# (Full street address & local authority)
Destination address# (Full street address & local authority)
Queensland Police#
Permit issuing location

#(Required for building movements)

Proposed routes (single trip) (All proposed state controlled roads MUST be listed – include road numbers if available)

5. Mass information (Required for all Excess Mass related permits)

Mass of special purpose vehicle

Tare / Total mass

Mass of prive mover and trailer/s

Total tare / Mass of load (100 tonnes and over requires written confirmation of the load) / Total mass

Loading information (Prime mover and trailer/s only)

Description of load

Axle / Axle group information

Axle No. / Distance from previous axle / No. of tyres per axle / Tyre width / Ground contact width / Axle mass requested / Office Use Only
Permit Axle Mass
1 / mm / m / t
2 / m / mm / m / t
3 / m / mm / m / t
4 / m / mm / m / t
5 / m / mm / m / t
6 / m / mm / m / t
7 / m / mm / m / t
8 / m / mm / m / t
9 / m / mm / m / t
10 / m / mm / m / t
11 / m / mm / m / t
12 / m / mm / m / t
13 / m / mm / m / t
Total permit gross mass

Note: If more axles are required, attach a copy of this page.

6. Dimension information

Loading information (Prime mover and trailer/s only)

Description of load

Overall dimension of special purpose vehicle

Length / m / Height / m / Top width / m / Base width / m

Overall dimension of vehicle combination – including load (Required for load carrying vehicles)

Length / m / Height / m / Top width / m / Base width / m

Description of building (Complete for building movements)

Roof description
Roof position / On / Off / Lowered
Building owner
Cut into sections / No / Yes ► / Number of sections / Please complete overall dimensions below for second section.

Overall dimension of vehicle combination – including load (Required for second section of building movements)

Length / m / Height / m / Top width / m / Base width / m

Infrastructure modifications required

Street signs / Yes / No / Traffic lights / Yes / No
Bridge railings / Yes / No / Guide posts / Yes / No
Trees / Yes / No

7. Signature of Authorised "AHHO" or Authorised Agent

I hereby certify that the information supplied herein is correct, and in my authorised capacity, I accept liability for any damage done to any road declared under the Transport Infrastructure (Roads) Act 1994, and indemnify the Director General against any claim which may be sustained against him by reason of the use of any declared road for the purpose mentioned.

7.1 Excess Mass application or Excess Mass and Dimension Permit application

Full name / Position
Signature / Date
AHHO Number

7.2 Dimension Permit application

Full name / Position
Signature / Date
Privacy Disclaimer
The information on this form is collected under the authority of the National Heavy Vehicle Law 2013. The Department of Transport and Main Roads (the department) requires this information for the issuance of permits. Authorised officers from the department have access to this information and will not disclose your information to third parties without your consent or unless required by law.

Page 4 of 4 TRB Forms Area Form M4130 CFD V01 Feb 2014