Nebraska Department of Transportation Application for Encroachment	Date of Application:	Fax No.:	Email:
Type of Application:
Sign	Awning	Mansard Roof
Other
Encroachment Owner:	LOCATION OF ENCROACHMENT
City/Town:	County:
Address: (Box, Street or Route No)
Highway No.:	Side of Highway: N S E W	R.P.:
City:	State:	Zip:
Sta. No.:	Rt.	Illumination: Yes No	Date Existing Encroachment Erected:
Telephone No.: (include Area Code)	On Project: Yes No	Control No.:	Lt.
Height Above Sidewalk to Bottom of Encroachment:	Width of Sidewalk from Back of Curb to Property Line or Building:
Project No.:
If Sign, Advertising Copy Reads:	SIZE OF ENCROACHMENT
Width:	Length:	Height:

Sketch of Encroachment: (The sketch is to be a side view that includes dimensions that indicate how much the encroachment extends into the right of way):	Affix Photo Here of Encroachment Location:

I certify all information provided above is true and accurate.	District Comments:
I assign the right to the State of Nebraska Department of Transportation 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.
Owner of Record (Signature):	Date:	District Engineer, Department of Transportation: (Signature)	Date:

NDOT Form 26, July 17