The following form may be filled out signed, dated and mailed or faxed to the appropriate District Permit Officer.

District 1

Nebr. Dept. of Transportation

District 1 Permit Officer

302 Superior St

Lincoln NE 68521-2481

Phone:	(402) 471-0850

Fax:	(402) 471-3401

District 2

Nebr. Dept. of Transportation

District 2 Permit Officer

4425 S 108th St

PO Box 45461

Omaha NE 68145-0461

Phone:	(402) 595-2534

Fax:	(402) 595-1720

District 3

Nebr. Dept. of Transportation

District 3 Permit Officer

408 N 13th St

Norfolk NE 68701-3714

Phone:	(402) 370-3470

Fax:	(402) 370-3473

District 4

Nebr. Dept. of Transportation

District 4 Permit Officer

211 N Tilden

PO Box 1488

Grand Island NE 68802-1488

Phone:	(308) 385-6265

Fax:	(308) 385-6269

District 5

Nebr. Dept. of Transportation

District 5 Permit Officer

140375 Rundell Rd

PO Box 220

Gering NE 69341-0220

Phone:	(308) 436-6587

Fax:	(308) 633-6614

District 6

Nebr. Dept. of Transportation

District 6 Permit Officer

1321 N Jeffers

PO Box 1108

North Platte NE 69103-1108

Phone:	(308) 535-8031

Fax:	(308) 535-8034

District 7

Nebr. Dept. of Transportation

District 7 Permit Officer

619 Auditorium Dr

McCook NE 69001-3569

Phone:	(308) 345-8490

Fax:	(308) 345-8492

District 8

Nebr. Dept. of Transportation

District 8 Permit Officer

736 E 4th St

Ainsworth NE 69210-1215

Phone:	(402) 387-2471

Fax:	(402) 387-1498

Nebraska Department of Transportation Application for Junkyard Permit	Date of Application:
Existing Sign – Date Erected:

Attach the following to the application

1) If tenant, a copy of the lease with the landowner. 2) A plot plan showing the location of the junkyard. 3) A copy of the permit or a copy of a written approval from the Local Permit Authority that they will issue a permit for this specific junkyard contingent upon the Nebraska Department of Transportation issuing a permit for this specific location. 4) Screening plan, if required. (See Screening Criteria below.)

Name of Junkyard Owner:	Telephone No.:	Name of Landowner:	Telephone No.:	OFFICE USE ONLY
Name to be Printed on Permit:	Address:
Address:
PERMIT NUMBER
SCREENING CRITERIA Junkyards established after August 27, 1971, which are not in areas zoned or unzoned industrial shall submit a plan for screening the junkyard from view of the traveling public. The Department will determine if the screening is acceptable and can be maintained to a standard to comply with the rules. See NAC Title 410, Chapter 4, Section 009.
Verification of Zoning of Junkyard Location	Verification of Unzoned Location
Zoning Jurisdiction of: (City or County)	Jurisdiction of: (City of County)
Zoning Type: (attach copy of zoning map of the sign location)	The location where this junkyard is to be located is unzoned.
Industrial:	Note specific zoning category:	Printed Name of City or County Clerk verifying junkyard location is unzoned.
Dated:
Printed Name of Local Zoning Authority (verifying zoning of location): Dated:
Signature of City or County Clerk verifying junkyard location is unzoned.
Signature of Local Zoning Authority(verifying zoning of location): Dated:	Dated:
LOCATION OF JUNKYARD
County:	Hwy. No.:	Side of Hwy.: N S E W	Reference Post to Nearest Tenth of a Mile (Example 80.2):
Section:	Township:	Range:	If platted, provide lot, block, and subdivision:
APPLICANT REMARKS	APPLICANT CERTIFICATION
I certify all information provided above is true and accurate. A permit issued pursuant to this application may be revoked and applicant’s junkyard removed by the Nebraska Department of Transportation at applicant’s expense if: 1. Applicant has provided false or misleading information on this application. 2. The establishment of a junkyard which violates State or local laws regarding zoning or violates State laws or Nebraska Department of Transportation’s rules and regulations NAC Title 410, Chapter 4.
Printed Name of Applicant:
Signature of Applicant:	Date:
Above signature is of: Owner Officer Agent
Address of Officer or Agent:
Phone No.:
NEBRASKA DEPARTMENT OF TRANSPORTATION, LINCOLN OFFICE USE ONLY
Business Check Personal Check Other (describe):	Office Remarks:
Check No.: Amount: Date Received: Initial:
Staff Review (Initial and Date):	Supervisor Review (Initial and Date):

NDOT Form 216, July 17