Fillable Printable Form 4591
Fillable Printable Form 4591
Form 4591
OUTDOOR ADVERTISING SIGN
PERMIT APPLICATION
State Form 45918 (R8 / 6-16)
Approved by State Board of Accounts, 2016
INDIANA DEPARTMENT OF
TRANSPORTATION
100 North Senate Ave. Room N925
Indianapolis, IN 46204
DO NOT WRITE IN THIS BOX –
FOR DEPARTMENTAL USE ONLY
Date received (month, day, year)
Application number
A $100.00 non-refundable application fee is due upon receipt of this application.
Permit number
Fee receipt number
Type of request
Proposed sign Existing sign Addendum Name transfer Changeable message sign
1. Name of sign owner / applicant
Telephone number
( )
Address of sign owner / applicant (number and street, city, state, and ZIP code)
Name of representative
E-mail address of representative
2. Name of property owner
Telephone number
( )
Address of property owner (number and street, city, state, and ZIP code)
2(a). A property owner permission affidavit must be attached to this application.
SIGN LOCATION (Proposed signs must be staked at the time of application.)
3. Type of highway
Interstate US SR
Highway number
Estimated erection date (month, day, year)
4(a). Side of highway
Right Left
4(b). Direction of travel
North South East West
5. Between reference signs / mile markers
and
Miles measured from reference point
6. Location Description (Sketch must be attached.)
Name of county
6a. Feet to nearest sign (excluding official,
directional, on premise and “For Sale” signs)
6b. Feet from right-of way line of highway checked in
item 3 (Must be within 660 feet of the right of way.)
6c. Distance to nearest intersection / ramp
Direction
North South East West
Specify which intersection / ramp
6d. Can sign be seen from a scenic byway?
Yes No
If yes, name of scenic byway
6e. Is highway a limited access facility?
Yes No
7. Is sign located in an unzoned commercial or industrial area?
Yes No
If unzoned, identify qualifying commercial or industrial activity.
8. Is sign located in a zoned commercial or industrial area?
Yes No
9. City or county permit number, if any
Zoning classification (primary)
Explain zoning classifications (Zoning affidavit and local building permit must be attached.)
10. Is sign within city limits?
Yes No
Denote controlling municipality
11. Was the property rezoned for the purpose of
erecting a billboard after March 15, 1986?
Yes No
Was any zoning action taken by the applicant or the property owner
for the purpose of erecting a billboard after March 15, 1986?
Yes No
SIGN DESCRIPTION
12. Estimated height from ground to highest point (feet)
13. Width of face, excluding border (feet)
Height of face, excluding border (feet)
Area, excluding border (square feet)
14. Type of sign
Single face Back to back V type Side by side Double deck Attached to building Other:
15. Number of supports
Type of supports
Wood Steel Monopole Other:
16. Illuminated?
Yes No
17. Does the sign advertise only activities taking place on the property where the sign is located?
Yes No
Changeable message sign?
Yes No
CERTIFICATION
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 erect the structure described herein.
Signature of applicant Date (month, day, year)
DO NOT WRITE BELOW THIS LINE - FOR DEPARTMENTAL USE ONLY
Additional special provisions
Determination
Legal Permit Conditional Permit Official Directional Religious or Public Service Denial
Signature of District Regulatory Supervisor Date (month, day, year)
ALL PERMITS ARE SUBJECT TO STANDARD GENERAL PROVISIONS. SEE ATTACHED FOR 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.
For records retention, refer to 83-602.
Reset Form
INDIANA DEPARTMENT OF TRANSPORTATION
OUTDOOR ADVERTISING SIGN PERMIT
GENERAL PROVISIONS
The following provisions apply to all outdoor advertising sign structures unless specifically noted in the permit standard.
SPECIAL PROVISIONS
1. Signs which attempt or appear to attempt to regulate, warn, or direct the movement of traffic, or which interfere with,
imitate, or resemble any official traffic sign, signal or device are not allowed.
2. Signs are not allowed that prevent the driver of a vehicle from having a clear and unobstructed view of official signs,
approaching signs, approaching traffic or merging traffic.
3. The permittee shall notify the Department of Transportation Subdistrict Permit Investigator five (5) working days
preceding the beginning of any work activity.
4. The permittee shall notify the Department of Transportation Subdistrict Permit Investigator that the work is complete
and this notice is to be provided within seven (7) days from completion of all work on this permit.
REVOCATION OF PERMIT
Any valid permit issued for a lawful outdoor advertising structure shall be revoked by the Indiana Department of
Transportation for any of the following reasons:
1. Mistake of material facts by the issuing authority for which had the correct facts been made known, the outdoor
advertising permit in question would not have been issued;
2. Misrepresentations of material facts by the applicant for the outdoor advertising permit;
3. Failure to complete construction of structure within 365 days from the date of issuance of the outdoor advertising
permit;
4. Any alteration of an outdoor advertising structure for which a permit has previously been issued which should cause
that outdoor advertising structure to fail to comply with the provisions of the Out
door Advertising Control Act and the
rules and regulations promulgated by Indiana Department of Transportation pursuant thereto;
5. Making alterations to a non-conforming sign which would cause it to be other than substantially the same as it was on
the date the sign became non-conforming. (See section on Non-conforming signs.)
6. Failure to affix permanent permit plate within thirty (30) days after the erection of the outdoor advertising structure;
7. Unlawful destruction of trees or shrubs or other growth located on the right-of-way in order to increase or enhance the
visibility of an outdoor advertising structure;
8. Unlawful violation of the control of access on interstate, freeway, and other controlled access facilities. Direct access
to a billboard from an interstate is strictly prohibited.
9. Failure to maintain a sign such that it remains blank for a period of twelve (12) consecutive months;
10. Failure to maintain a sign such that it becomes obsolete.
