Application form for issuing the necessary permit (Annex No. 4 to art. 15, para 3 of Ordinance No. 11)

Ref. No. to ………………………………………..............................................................................

(administration managing the road)

APPLICATION

for the issuance of a permit for the movement of a heavy and / or oversized road vehicle

Applicant / carrier name: ...........................................         VAT No. ................................................

Address: .....................................................................               UIC / BULSTAT  .................................

Cargo owner: .................................................................................................................

Address and telephone number of the applicant: ...................................................................................................

Email: ……………………........................................................................................

With this document
I HEREBY DECLARE:
vehicle and load data as follows:

Tractor: ........................................... (brand)

Trailer (Semi-trailer): ............................ (brand)

1. Reg. No.  ................................................

2. Width: .................................. (m)

3. Height: ................................... (m)

4. Length: .................................... (m)

5. Own weight ........................... (t)

6. Ballast weight: ............................... (t)

8. Reg. No. ...................................................

9. Width: ..................................... (m)

10. Height: ..................................... (m)

11. Length: ...................................... (m)

12. Own weight ............................. (t)

13. Number of axles: front axles .... pcs., rear axles .... pcs.

7. Number of axles: front axles .... pcs., rear axles .... pcs.

7а. Type of suspension (pneumatic, including equivalent or not)

13а. Type of suspension (pneumatic, including equivalent or not)

Cargo: ............................................ (type)

14. Width: ............................ (m)

15. Height: .............................. (m)

16. Length: ............................... (m)

17. Own weight ................................................. (t)

General information on the oversized or heavy road vehicle:

18. Overall width: ............................................ (m) (max of p. 2, p. 9 и p. 14)

19. Overall height: .............................................. (m) (max of p. 3, p. 10 + p. 15)

20. Overall length: .............................................. (m)

21. Overall weight ......................................................... (m) (p.5+ p.6+ p.12 + p.17)

22. Diagram of the arrangement of the axles with indication of the distances between them and their respective load

Other information:

Starting point: .................................................. End point: .......................................................

I hereby declare that I am familiar with the provisions of Ordinance No. 11 of 2001 on the movement of oversized and / or heavy road vehicles.

Accompanying person: ..........................................................................................................................

Place of work: ........................................................... Position: ........................................................

I hereby declare that the accompanying person meets the requirements of art. 24 of Ordinance No. 11 of 2001 on the movement of oversized and / or heavy road vehicles.

I am aware that I am liable for false data declared by me under art. 313 of the Criminal Code.

Head

(Representing / Managing): ................................... (Name and surname) ............. (Signature and seal)