Fillable Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form forSignal Housings, Mounting Equipment, and Accessories

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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form forSignal Housings, Mounting Equipment, and Accessories

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Qualified Traffic Control Equipment Submission Form for
Signal Housings, Mounting Equipment, and Accessories
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. 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 Mod
el #
Description
Link to product cutsheet
Product Type
Vehicle Housing Pedest
rian Housing
Mounting Hardware Signal Backplate
Other:
Part C. Technical Product Information
Please complete this section for vehicle and pedestrian housings, only.
Housing Material(s)
Hardware
Material(s)
Available Colors
Dimensions
Weight
Please complete this section for signal & component mounting hardware, only.
Mou
nt Type
Post Top Side Mount
Mast Arm (Rigid) Mast Arm (Free)
Other:
Material(s)
Application Revision: November 12, 2014 Signal Housings and Mountings Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 3
Please complete this section for signal backplates, only.
Backplate Material(s)
Available Colors
Dimensions
Louvers Yes No
Retroreflective Border Yes No
If Yes,
list dimensions:
Technical Notes (if necessary):
Part D. Product Use
Has this
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
If Yes, please explain:
Is t
his 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 No
If Yes, for how long?
I
f 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 12, 2014 Signal Housings and Mountings 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 T
itle
Company
Website
Address City, State ZIP
Email Phone
Reference #1
Contact Title
Agency
Email 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 12, 2014 Signal Housings and Mountings 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 forSignal Housings, Mounting Equipment, and Accessories

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Completed 13 May 2020

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