Form Dt 0266 – Fill Out and Use This PDF

Outdoor Advertising Device Application, State of Tennessee, Department of

Transportation, Environmental Division, Beautification Office

Please Type or Print Clear – Press Hard Type of Application (Check One): Original Application ____						Application for Expired Permit _____
1.	Name of Applicant			2.	Mailing Address
3.	City	4. State	Zip Code	5.	Phone Number (Include Area		6. Application Date
				Code)

7. Property Owner Name and Mailing Address (Required State and Zip Code)

Location of Outdoor Advertising Device

8. Highway Route Number			9. County Name						10. Is this a Fully Controlled Access Highway?
Interstate #		Primary Hwy or NHS
__________		State Route# ______							Yes ____ No ____
			____________________
11. Is the sign within 1,000 feet of an entrance or						12. Is the sign within the corporate limits of a city or town: Yes ___ No ___
exit ramp?		Yes _____ No _____				If YES, name of City or Town ____________________________________
13. Nearest Intersecting Highway or Road					Direction from			14. Present Zoning of Site		15. Name of qualifying activity if
Intersection		_____________________		North ____ South ___						unzoned commercial or industrial:
Distance from Intersection __________				East ____ West			___

16. Distance to nearest outdoor advertising device in each direction on the same side of the road

COMPLETE TWO: __________ Ft. South, __________ Ft. North, __________ Ft. East, __________, Ft. West

17. Is this application for	18. If the answer to item 17 is YES,	19. Previous Permit or Tag	20. Will Outdoor Advertising Device be a
an existing sign?	when was the sign erected?	Number __________	back to back or V-Type structure?
Yes _____ No ____	______		Yes ______ No ______

Face Type, Materials and Configuration – You are required to build whatever you apply for on your application if issued permit.

21. Is this application for	22. Sign Face Area:	23. Shape:		24. Sign Face	25. Lighted Yes ___ No___
transferring a	_______ Sq. Ft.			Material:	Face Type:
Permitted Stacked		______	Square	Face:	26. Stretch Vinyl or Other
Device	Face Dimensions:	______ Triangular		____ Wood	Yes ____ No____
Yes ____ No ____		______	Circular	_____ Metal
	Height ________Ft.	______	Rectangular
				_____ Other	27. Mechanical Changeable
If yes, list tag #:		______	Other
					Panels: Yes_____ No_____
____________	Width ________ Ft.
					**28. Digital Display or LED:
					Yes_____ No _____

NOTE: The following Must Accompany This Application – Whatever is stated on application will be required be built if permitted. 1) A check or money order in the amount of $200.00 payable to TDOT for application fees and any additional fees for expired permits.

2) A copy of a signed notarized affidavit by the property owner stating permission has been given to erect a sign. Property owner’s signature must be notarized. A copy of property owner’s recent property record from the Assessor of Property Office. If this record is available on-line, a printout is acceptable.

3) A map or scaled drawing on a separate piece of paper which shows the location of the proposed outdoor advertising device on private property. It is mandatory to show the property lines and the State’s highway right-of-way and to include any cross roads.

Please refer to the rules before applying for this permit.

Field Inspection Requirement: The applicant must mark the proposed sign location with an easily visible flag or stake. Failure to properly mark a proposed location will result in the rejection of this application; the application fee will be retained as required by law.

This application is for a permit for one face of an outdoor advertising device. The permit is not transferable to another Outdoor Advertising Device. I hereby certify that I have personally examined and understand the “Rules and Regulations for the Control for Outdoor Advertising” and this application is made in compliance with same, and further certify that the statements made on the application are accurate and true to the best of my knowledge and understand that if investigation reveals that any of the information on the application is false the permit will be voided, tag confiscated, and the Outdoor Advertising Device will be declared illegal.

I also certify that the only Vegetation Control to be performed at this location for signs erected after April 20, 1983, will be in accordance with the Rules and Regulation.

Signed ______________________________________________ Name Typed or Printed __________________________________

Department of Transportation

CENTRAL OFFICE USE ONLY

DATE OF ISSUANCE

ISSUED BY

TAG NUMBER

COUNTY

ROUTE

LOG MILE

Return White and Canary Copies to Beautification Office – ODA, Suite 400 James K.

Polk Bldg., Nashville, TN 37243-0333 (Please Retain Pink (last) copy for your files.)

** Item 28 is required to be marked Yes if you are applying for & going to build a Digital Display, LED.

DT-0266

JANUARY 2010