e authors of this page or responsible for its content. NCRR FORM 210










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010105E

HNTB
Corporation


APPLICATION FOR UNDERGROUND/AERIAL WIRELINE

OCCUPANCY

APPLICANT MUST ANSWER ALL APPLICABLE QUESTIONS AND RETURN THIS
FORM TO:

HNTB North Carolina, P.C.
Phone: (919) 546-8997
343 E. Six Forks Road, Suite 200 Fax: (919) 546-9421
Raleigh, North Carolina 27609

Attn: Manager, NCRR Pipes and Wires

Occupancy Agreement Process


For NCRR / HNTB use only
File No. __________________
NCRR ID #: _______________


Plans for proposed installations are to be submitted to, and shall meet the approval of,
North Carolina Railroad Company before construction is begun. Materials and installation
are to be in strict accordance with specifications of the American Railway Engineering
and Maintenance-of-Way Association (AREMA), North Carolina Railroad Company, and Norfolk
Southern Corporation and/or CSX Transportation as appropriate. The information submitted
with this application and the required number of copies shall be per the Pipeline and
Underground/Aerial Wireline Occupancy Application Instructions (NCRR Form 230) and
Underground/Aerial Wireline Occupancy Applicants Checklist (NCRR Form 240).

Applicant/Project Owner Information
1. Legal Name of Applicant (party to agreement):_________________________________________
______________________________________________________________________________________
2. Street Address of Applicant: _________________________________________________________
City________________________________ State______ Zip_______
3. Mailing Address of Applicant (if different):
Street ______________________________________________
P.O. Box ______________
City _______________________________ State______ Zip ______
4. Name of Applicants Representative: __________________________________________________
Title: _____________________________________________
Telephone Number: (___) ___ - ______ Ext. _____ Email: _______________________________
Fax Number: (___) ___ - ______ Email: ____________________________________________
5. Billing Address: Street_______________________________________________________________
City________________________________ State_______ Zip_______
6. Name of Contact for Billing Purposes: ________________________________________________
Title: _____________________________________________
Telephone Number: (___) ___ - ______ Ext. _____ Email: _______________________________
7. Billing: Applicant prefers ( ) yearly ( ) one time non-assignable payment.
8. Applicant is a: [ ] Corporation State of formation: ___; [ ] Limited Partnership
state of formation: ___; [ ] General Partnership state of formation: ____
[ ] Sole Proprietorship Give name of owner: _________________________________
[ ] Individual [ ] Government Entity
[ ] Other: ____________________________________________________________________

Applicants Engineer/Consultant Information
9. Company Name: _______________________________________________________________________
10. Contact Person Name: ________________________________ Title: ________________________
Street Address: _____________________________________________________________________
City: _____________________________________ State: _______ Zip: ______
NCRR FORM 210



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010105E

Applicants Engineer/Consultant Information (Cont.)
Telephone Number: (___) ___ - ______ Ext. ______
Fax Number: (___) ___ - _____ Email: ______________________________________________

Project Information
11. Installation is: [ ]New [ ]Revision to existing [ ]Attachment to existing

[ ]Upgrade to existing.
Are there any agreements covering the wire line? [ ]Yes [ ]No [ ]Do not know
If yes, identify and attach copies: ________________________________________________
12. Location of Installation:
Nearest Street _________________________ Nearest Town ______________________________
County _______________________________ State _______________________________________
Railroad Milepost Reference: _________ Feet N E S W of Milepost ____________________






(Circle one)

Latitude: _______________________ Longitude: _______________________________________
13. Will installation be located entirely within the confines of a public street?
[ ] Yes [ ] No
If yes, provide conclusive evidence for verification and show road name, number and
width on drawing.
Street width: _______________ Feet Street Right-of-Way width: _______________ Feet
DOT/AAR Crossing No. ____________
Valuation Station of Crossing if Known: ___________________ Val. Map No. __________
Road Authority Responsible for Street Maintenance
Name: _____________________________________________________________________________
Address: __________________________________________________________________________
Contact Person:__________________________________ Telephone No. (___) ____ - ______
14. Type of Installation: [ ]Cable TV [ ]Telephone [ ]Electric Power [ ]Fiber Optic
[ ]Communications [ ]Other(Specify): _______________________
15. Installation is: [ ]Trunk [ ]Distribution [ ]Transmission [ ]Other
16. Conductors: Number: _______
Material: [ ]copper [ ]aluminum [ ]fiber optic, fiber count _________
AWG Gauge: _______________
17. [ ]AC /[ ]DC: Voltage: ________ No. of Phases: _____ Amperes: ______ Hertz: _______
18. Maximum voltage: ________________ Maximum Current: ________________
19. Maximum fault to ground current: _____________
20. Is this a [ ]Crossing [ ]Parallelism [ ]Both?
21 For a Crossing: Number of tracks to be crossed: _____ Angle of Crossing: __________



Total crossing on Railroad Right of Way: _______________ Feet
22. For a Parallelism: Begin at __________ feet N E S W of RR Milepost ________________






(Circle one)


End at ____________ feet N E S W of RR Milepost ________________






(Circle one)


Total length on NCRR right of way: _____________________________

Length Parallel: _____________ Length crossing: ________________
23. Will the installation connect to an existing facility within the NCRR right-of-way?
[ ]Yes [ ]No If yes, identify owner: ______________________________________________
24. Type and quantity of facilities to be installed on NCRR right-of-way: [ ] Manholes
[ ] Handholes [ ] Pull Boxes [ ] Other(Identify) ______________________________
Distance from nearest track: ________________ Feet
Show locations and dimensions on the drawings.
25. Number of new poles to be installed on NCRR right-of-way: _________________________
26. Number of existing poles to be utilized on NCRR Right-of-way: _____________________
27. Distance from butt of pole to nearest rail of track: ____________ feet
28. Identify each intended user of the installation: __________________________________
29. Name of contractor: _______________________________________________________________
30. Proposed installation date: _______________________________________________________
31. Define any special specifications of the installation: ______________________________
_____________________________________________________________________________________ NCRR FORM 210



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010105E

Underground Facilities
32. Total buried length on NCRR right-of-way: _______________________
33. Total Number of Conduits: ______ Number empty: ________ Number filled: ________
34. Number of cables or lines in each conduit: _________________
35. Number of conductors in each cable or line: ________________
36. Encasement Material: ______________ Outside diameter: _______ Wall thickness: _______
37. Bury depth:

From base of rail to top of casing: _____________ feet

Minimum depth on right-of-way but not beneath tracks: ______________ feet

Below ditches: ________________ feet

Aerial Facilities
38. Total aerial length on NCRR right-of-way: _____________________feet
39. Number of cables or wires: _____________
40. Number of pole lines crossed: ____________
41. Type of wire supports: __________ Size: __________ False dead ends: ________________
42. Height of wires above top of rail at 60�F: _________ Feet
43. Sag in Spans at 60�F: ____________ Feet
44. Height of wires above Railroad communication and signal wires at 60�F: ________ Feet
45. Horizontal distance from railroad communication and signal wires: __________Feet
46. Height of wire supports above ground: ____________ Feet

Fiber Optic Facilities
47. Number of fibers per cable: ___________
48. Identify each intended user of the conduit/cable: __________________________________


If the application is approved, the Applicant agrees to reimburse the North Carolina
Railroad and the Operating Railroads for any cost incurred by the North Carolina
Railroad and the Operating Railroads incident to installation, maintenance, and/or
supervision necessitated by this installation, and further agrees to assume all
liability for accidents or injuries which arise as a result of this installation.

______