State Permit Application.tif i
Date of Application: Fax No.: Email:
6/21/11 402 - 330 -9280 steve @heartlandawnIng.co
Nebraska Department of Roads m
Application for Encroachment Type of Application:
® Sign ® Awning ❑ Mansard Roof
❑ Other
Encroachment Owner: • • • • '
HunTel Engineering Attn: Rick Plugge City/Town: County:
Address: (Box, Street or Route Ni Blair Washington
1613 Washington Street Highway No.: Side of Highway: R.P.:
City: State: Zip: 30 ❑ N ® S E I E ❑ W
Blair NE 68008 Sta. No.: ❑ Rt. Illumination: Date Existing
Encroachment
Telephone No.: (include Area Code) On Project: Control No.: ❑ Lt. ❑ Yes ® No Erected:
402 - 426 -6235 ® Yes ❑ No Height Above Sidewalk to Bottom of Width of Sidewalk from Back of Curb
Project No.: Encroachment: to Property Line or Building:
86 " 18
If Sign, Advertising Copy Reads: NOR • •
HunTel Engineering Width: Length: Height:
2 29' 4'
Sketch of Encroachment: (The sketch is to be a side view that includes Affix Photo Here of Encroachment Location:
dimensions that indicate how much the encroachment extends into the
right of way):
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I assign the right to the State of Nebraska Department of Roads to
act as my agent to remove the above encroachment if I, the owner,
have failed to remove the encroachment after the 10 -day written
notification. If there is a change in ownership of encroachment, new
owner agrees to permit stipulations or removes encroachment.
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Owner of Record (Signature): Date: District Engineer, Department of Roads: (Signature) Date:
DR Form 26, May 04
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