MDT Use Only Permit #: ______________ ☐ Approved ☐ Denied Date: _________________
OAC Agent
OAC Supervisor
SIGN OWNER/APPLICANT

First Name:
Last Name:

Address:	City, ST, Zip

Email:	Phone:	Permit #:

CONTRACTOR INFORMATION

First Name:
Last Name:

Address:	City, ST, Zip

Email:	Phone:

LOCATION

Highway #:	Side of Hwy:	☐ North	☐ South	☐ East	☐ West

City/Town:	County:

Nearest Mile Marker or Address of Sign Location:

TYPE OF VEGETATION REMOVAL (sign must be 2 years old)

☐ Trim Brush	☐ Trim Trees

INCLUDE THE FOLLOWING INFORMATION

1.	Proof of service of notification to adjacent property owners.	CAUTION Failure to stay in compliance with All local sign regulations may result In revocation of this permit
2.	Proof of liability insurance.
3.	Type of herbicides to be used, if any (Must be approved by the District.
4.	Site drawing showing vegetation to be affected.
5.	Proof of $1000 performance bond or $1000 deposit.
6.	Encroachment permit approved by the District Maintenance Chief.

LOCAL GOVERNMENT APPROVAL OF SITE CLEARING

City/County of	☐ Site clearing approved	☐ Site clearing denied

LOCAL GOVERNMENT CERTIFICATION

By my signature/typewritten name, I declare under penalty of perjury and the laws of the State of Montana that the foregoing is true and correct and contains no willful falsifications of misrepresentations.

Signature	Date	Place of Signature (City, State)

CONTRACTOR CERTIFICATION

By my signature/typewritten name, I declare under penalty of perjury and the laws of the State of Montana that the foregoing is true and correct and contains no willful falsifications of misrepresentations.

Signature	Date	Place of Signature (City, State)

SIGN OWNER/APPLICANT CERTIFICATION

By my signature/typewritten name, I declare under penalty of perjury and the laws of the State of Montana that the foregoing is true and correct and contains no willful falsifications of misrepresentations.

Signature	Date	Place of Signature (City, State)

MDT CERTIFICATION

By my signature/typewritten name, I declare under penalty of perjury and the laws of the State of Montana that the foregoing is true and correct and contains no willful falsifications of misrepresentations.

Signature	Date	Place of Signature (City, State)