Fillable APPLICATION VIRGINIA BLANKET HAULING PERMIT (Virginia Department of Motor Vehicles)

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APPLICATION VIRGINIA BLANKET HAULING PERMIT (Virginia Department of Motor Vehicles)

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HP 401 (10/27/2020)
VIRGINIA BLANKET HAULING PERMIT
APPLICATION
Purpose: Use this form to apply for a hauling permit covering multiple moves. See
additional instructions on page 3 of this application.
Instructions: Mail or fax this form to the address or fax number above. Use the Virginia
Hauling Permit Addendum Additional Axle (form HP 403) for configuration
exceeding 9 axles. Use the Locality Blanket Permit Addendum form HP
406 to order locality blanket permits.
REQUESTED DURATION (subject to approval)
2 years
1 year
_______ months
REQUESTED EFFECTIVE DATE (mm/dd/yyyy) QUANTITY
SHIPPER (Hauling or Transport Company)
ID NUMBER (VAHPS ID, FEIN, OR SSN) GOVERNMENT MOVE (check one) CONTACT PERSON NAME
NAME (last) (first) (mi) (suffix)
MAILING ADDRESS
P. O. BOX, SUITE NUMBER (if applicable) EMAIL ADDRESS
CITY STATE ZIP CODE VA JURISDICTION (county or city—VA only) COUNTRY
Yes
No (must provide overhang width)
None
OVERALL DIMENSIONS/SIDE OVERHANG
HEIGHT
WIDTH
Is the overhang evenly distributed across the left and right sides of the transporter?
WIDTH OVERHANG
LEFT ______ feet ______ inches RIGHT ______ feet ______ inches
LENGTH LENGTH OVERHANG
FRONT ______ feet ______ inches REAR ______ feet ______ inches
SELF-PROPELLED CRANE
Width outside of left tire to outside of
right tire.
WIDTH _____ feet _____ inches
AXLE WEIGHT AND SPACINGS
GROSS WEIGHT
pounds
NUMBER OF AXLES
AXLE 1 2 3 4 5 6 7 8 9
WEIGHT
DISTANCE
(between axles)
COMPANY NAME
LICENSED LEGAL WEIGHT
VEHICLE AND LOAD SIDE OVERHANG
CRANE MAKE AND MODEL (if applicable)
COMMODITY AND VEHICLE
ITEM TO BE MOVED TRANSPORT METHOD (check one)
Haul Tow
Drive
VEHICLE ID LOCATION
Truck/Trailer Combination
Straight Truck
HAZARDOUS
Yes No
LICENSE PLATE NUMBER ISSUING STATE VIN/SERIAL NUMBER (last 5 digits)
TELEPHONE NUMBER
feet in
Federal State
See instructions above for configurations exceeding 9 axles.
feet
FAX NUMBER
inches
inchesfeet
inchesfeet
infeet feet in feet in feet in feet in feet in feet in
lbs lbs lbs lbs lbs lbs lbs lbs lbs
Telephone: (804) 786-2787 ● Fax: (804) 367-1003
DMV USE ONLY
RECEIVED DATE (mm/dd/yyyy) REFERENCE NUMBER
CHECK NUMBER CHECK AMOUNT
( )
( )
HP 401 (10/27/2020)
Page 2
PERMIT FEES
1 year — $100.00 (If overweight, an additional $40.00 mileage and $360.00 damage fee per year will apply. If the vehicle or
the equipment being towed cannot be licensed in Virginia (i.e. Self-propelled crane, mobile home), a $40
mileage fee will apply.)
2 years — $200.00 (If overweight, an additional $40.00 mileage and $360.00 damage fee per year will apply. If the vehicle or
the equipment being towed cannot be licensed in Virginia (i.e. Self-propelled crane, mobile home), a $40
mileage fee will apply.
)
AUTHORIZED REPRESENTATIVE NAME (print)
AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
CERTIFICATION
My signature below certifies that I understand no amendments will be made to a Virginia Hauling Permit once it is issued.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand
that knowingly making a false statement or representation on this form is a criminal violation.
CHECK ONE:
/
State Abbreviation
Specific route (Complete Section A below.)
All Unrestricted Routes (Skip to Certification Section)
State Line
N S E W
on route
My DIRECTION will be (check one):
I am STARTING at (check appropriate box):
Provide additional starting point information ONLY if starting within Virginia.
miles
The starting point is
from starting address
ROUTE REQUESTED
City
City Name
/
County Name
County
N S E W
of route
/
State Abbreviation
State Line
N S E W
on route
My DIRECTION will be (check one):
I am ENDING at (check appropriate box):
Provide additional ending point information ONLY if ending within Virginia.
miles
The ending point is
to ending address
City
City Name
/
County Name
County
N S E W
of route
ROUTE INFORMATION
DELIVERY (For current pricing, refer to Virginia hauling permit price list available on our website.)
DELIVERY (check one) (NOTE: For payment and delivery information please refer to the instructions on page 3 of this application.)
USPS
FAX
HP 401 (10/27/2020)
INSTRUCTIONS FOR COMPLETING THE VIRGINIA
HAULING PERMIT BLANKET PERMIT APPLICATION
Requested Duration — Choose from 2 years, 1 year or enter the number of months desired.
Requested Effective Date — Date you wish the permit to start.
SHIPPER
New Shipper Location — Check if this shipper has not been previously issued a permit in Virginia Automated Hauling Permit System
(VAHPS) or if it is an additional location for this shipper.
Shipper Address Change — Check if this application records an address change.
ID Number — If the shipper has a VAHPS ID, enter it here. Otherwise enter the shipper's federal employer identification number (FEIN) or social security
number (SSN).
Government Move — Choose federal, state, or local if this permit is being ordered to conduct a government move.
Contact Person Name — Name of the person responsible for the permit. (Contact person name will be displayed on the permit document.)
Company Name — Name of the shipper.
Name — If the shipper is a person, complete name first, last, middle initial, and suffix name box.
Telephone Number — Phone number for the contact person displayed on the permit document.
Mailing Address — Mailing address for the shipper.
Fax Number — Fax number of the shipper.
P. O. Box , Suite Number — Post office box number and/or suite number if applicable.
Email — Email address of the contact person.
City — City where the shipper is located.
State — State where the shipper is located.
Zip Code — Postal zip code where the shipper is located.
VA Jurisdiction — County or city where shipper is located (for Virginia shippers only).
Country — Country in which the shipper is located.
COMMODITY AND VEHICLE
Item to be moved — Name of the item to be moved (e.g., truck bed, crane, excavator storage container).
Crane Make and Model — If the item being moved is a crane, enter the make and model.
Transport Method — Indicate how the item will be moved: hauled, towed or driven.
Hazardous — Check if the item is hazardous.
Vehicle ID Location — Check if using the license plate or serial number of a truck and trailer combination (trailer) or straight truck (truck).
License Plate Number — Enter the license plate number.
Issuing State — Enter the state from which the license plate is issued.
VIN/Serial Number — Enter the last 5 numbers of the Vehicle Identification Number (VIN) or serial number if the transporter is not licensed.
OVERALL DIMENSIONS/SIDE OVERHANG
Vehicle and Load — Enter the overall height, width and length measurement (feet and inches) of the vehicle and load combination being moved.
Overhang Boxes — Side Overhang — Check the appropriate box for overhang distribution. Width Overhang — If you answer no to side overhang, you
must complete the width overhang boxes.
(If you answer no you must complete the width overhang boxes.)
Length Overhang — Enter how much load hangs over the front and rear of the trailer.
Self-propelled Crane — If driving a crane, enter the width from outside of left tire to outside of right tire.
AXLE WEIGHT AND SPACINGS
Gross Weight — Enter the total weight of the vehicle configuration and load.
Licensed Legal Weight — Enter weight for which the vehicle is legally licensed.
Number of Axles — Enter the total number of axles including the axles on the power unit, trailer and dolly.
If you exceed 9 axles, check the box and complete the additional axle, Virginia Hauling Permit Additional Axle (form HP 403).
Axle — Circle one for each axle.
Weight — Enter the individual weight for each axle circled.
Distance — Enter distance in feet and inches between each pair of axles.
ROUTE
Check to indicate whether you are applying for unrestricted routes or a specific route.
For All Unrestricted Routes — Leave all other route information blank.
Specific Route — Complete all route boxes.
Starting — Check the appropriate box to indicate the starting point of the trip. Fill in the blank to indicate name of starting point.
Direction — Check which direction you will be heading. Enter route number. If you will be starting within Virginia, enter the distance and direction from the
intersecting route nearest your starting address and starting route number.
Ending — Check the appropriate box as to where you are ending. Fill in the blank to indicate name of ending point.
If you will be ending within Virginia, enter the distance and direction from the intersecting route nearest your ending address and route number.
Route Requested — Enter the desired route you wish to travel.
SIGNATURE
Name — Print the name of the person completing this form.
Signature — Written signature of the person completing this form.
Date — Date this application was signed.
PAYMENT/DELIVERY — Check the requested delivery method. Mail payment with completed application. For credit card payment, fax or mail the
application and the Hauling Permit Office will contact you for payment when the permit is ready to be processed.
Page 3
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APPLICATION VIRGINIA BLANKET HAULING PERMIT (Virginia Department of Motor Vehicles)

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Completed 2 November 2020

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