Fillable Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Controller Cabinets, Pull Boxes, and Other Traffic Signal Enclosures

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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Controller Cabinets, Pull Boxes, and Other Traffic Signal Enclosures

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The Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Controller Cabinets, Pull Boxes, and Other Traffic Signal Enclosures form is 3 pages long and contains:

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Qualified Traffic Control Equipment Submission Form for
Controller Cabinets, Pull Boxes, and Other Traffic Signal Enclosures
Submission Instructions: Please submit one application per product. Catalogue cuts shall be included as
attachments. If applicable, NEMA test results from an independent test lab shall be submitted to ensure
compliance. Independent laboratory load testing for all underground enclosures is required. All other testing
results or certifications which may assist in evaluation may also be included. All equipment shall comply with the
latest editions of Section 815 - Traffic Control Signals of the Standard Specifications
, including Supplemental and
Interim editions, NEMA, the Massachusetts Electrical Code, and applicable Underwriters Laboratories standards.
Upon evaluation MassDOT Highway Division will contact you.
Part A. Applicant Information
Today's Date
Name
Company
Address
City, State ZIP
Phone
Email
Part B. Basic Product Information
Name or Mode
l #
Description
Link to product cutsheet
Product Type
Controller Cabinet
Pull Box
Other Cabinet:
Other Enclosure:
Part C. Technical Product Information
Please complete the following section for cabinets, only.
Exterior Dimensions
Interior Dimensions
Door Dimensions
Shelves
Cabine
t Material(s)
Available Finishes
Mount Type:
Ground/
Concrete Pad Pole
Other:
Application Revision: November 7, 2014 Traffic Signal Enclosures Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 3
Please complete the following section for pull boxes and other underground enclosures.
Exterior Dimensions
Interior Dimensions
Enclo
sure Material(s)
Lid Coefficient of Friction
ANSI/SCTE Test Level
Box:
Lid:
Technical Notes (if necessary):
Part D. Product Use
Has t
his product, or one similar, been previously submitted to MassDOT? Yes No
If Yes, please explain:
Is this a replacement product for one currently approved by MassDOT? Yes No
I
f Yes, please explain:
Is this product currently in use in Massachusetts? Yes No
If Yes, please explain:
State DOTs that have
approved this product:
Is this product in commercial production? Yes N
o
If Yes, for how long?
If No, please explain:
Have there been any recalls on this product? Yes No
If Yes, please explain:
Recommended Routine Maintenance Program (if applicable):
Warranty Information:
Application Revision: November 7, 2014 Traffic Signal Enclosures Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 2 of 3
Part E. Contact Information
Supplier/
Distributer
Contact Title
Company
Website
Address City
, State ZIP
Email Phone
Manufacturer
Contact Tit
le
Company
Website
Address City, State ZIP
Email Phone
Reference #1
Contact Title
Agency
E
mail Phone
Reference #2
Contact Title
Agency
Email Phone
(This space may be used to provide additional information)
Applications may be submitted to james.danila@dot.state.ma.us or by mail to:
Jim Danila, P.E., Assistant State Traffic Engineer
Traffic and Safety Engineering Section, MassDOT Highway Division
10 Park Plaza, Room 7210
Boston, MA 02116
Application Revision: November 7, 2014 Traffic Signal Enclosures Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 3 of 3
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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Controller Cabinets, Pull Boxes, and Other Traffic Signal Enclosures

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Completed 13 May 2020

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