Free 45918.xls - Indiana


File Size: 572.2 kB
Pages: 1
Date: May 13, 2008
File Format: PDF
State: Indiana
Category: Government
Author: JUDY ALLSTATT
Word Count: 561 Words, 3,635 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.in.us/icpr/webfile/formsdiv/45918.pdf

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OUTDOOR ADVERTISING SIGN PERMIT APPLICATION
State Form 45918 (R5 / 4-08) Approved by State Board of Accounts, 2008

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DO NOT WRITE IN THIS BOX FOR DEPARTMENTAL USE ONLY Date received Registration# Permit # Fee receipt # Expiration date

INDOT 100 N. SENATE AVE. ROOM N. 901 INDIANAPOLIS, IN. 46204

$25.00 Non-refundable Application Fee due upon receipt of application. $75.00 Permit Fee due if Application is approved.
ADDENDUM NAME TRANSFER

PROPOSED SIGN

EXSISTING SIGN

CHANGEABLE MESSAGE SIGN

TRI-VISON SIGN

1. Name and address of sign owner / applicant (Name) (Street) Representative (Telephone Number and E-mail Address) 2. Name and address of owner of property (Name) (Street) SIGN LOCATION (Proposed signs must be staked at the time of application ) 3. Type and Name of Highway: Interstate US (City) (Area code and Telephone number) (State) Estimated Erection Date SR Highway# (Zip Code) (City) (State) (Zip Code)

Side of Hwy N S E W Direction of Travel 4.(a) 4.(b) N S E W 5. Between Referrence Signs / Mile Markers Miles Measured From Reference Post & 6. Location Description: County Name (Sketch must be attached) a. Estimated feet to nearest sign (excluding offical, directional, on premise and "For Sale Signs.") b. Feet from right-of way line of highway checked in item 3 (Must be within 660 feet if the right of way) N S E W Specify which intersection / ramp c. Estimated distance to nearest intersection / ramp 7. Is sign located in an unzoned commercial or industrial area? If unzoned, identify qualifying commercial or industrial activity 8. Is sign located in a zoned commercial or industrial area? 9. City or county permit number if any Explain Zoning classifications 10. Is Sign Within City Limits? Yes No Zoning classification (Primary) Zoning Affidavit & Local Building Permit must be attached. Denote Controlling Municipality: Yes No Yes No

11. Was the propery rezoned for the purpose of erecting a billboard after March 15, 1986? SIGN DESCRIPTION: 12. Estimated height 13. Sign excluding border: 14. 15. 16. 17. Sign type: feet from ground to highest point Height of face feet V-type Steel No Side by Side

Width of face Back to Back Wood Yes

feet Double Deck Other (specify)

Area Other

square feet

Single Face

Number of supports: Illuminated

Does the sign advertise activities taking place on the property where the sign is located?

Yes

No

Under the penalty of perjury, I certify the above statements to be correct to the best of my knowledge and belief of the undersigned who is authorized to sign this application. I certify that I have obtained authorization from the property owner to errect the structure described herein. Date Signed: DO NOT WRITE BELOW THIS LINE - FOR DEPARTMENTAL USE ONLY ADDITIONAL SPECIAL PROVISIONS:

Determination: DISTRICT REGULATORY SUPERVISOR DATE Legal Permit Conditional Permit RIGHT OF WAY PERMIT COORDINATOR DATE Directional Denial Official Religious or Public Service

(ALL PERMITS SUBJECT TO STANDARD GENERAL PROVISIONS)
DISCLAIMER The issuance of this permit shall in no way preclude the actions of any state agency, including INDOT from instituting any action against the applicant for violations of any state or federal law, rule or policy, including violations of federal and state environmental laws and regulations, nor is this approval intended to influence any action currently pending before a local board, commission or agency. Please reference 105 IAC 7-3-1 et. al. for any explanation or information necessary to fill out this application. Failure to provide any information required by this application will cause it to be denied.