MDT Use Only Permit #: ______________ ☐ Approved ☐ Denied Date: _________________
OAC Agent
OAC Supervisor
SIGN OWNER/APPLICANT

First Name:
Last Name:

Address:	City, ST, Zip
Seasonal Address?	City, ST, Zip

Email:	Phone:	Permit #:

A photo verification of the existing sign condition prompting repair or maintenance must be attached to the notification form. Department response is not required prior to commencement of allowable maintenance, at permittee’s risk of later receipt of department noncompliance determination. If applicable, government issued buildings permit needs to be included with this form.

Provide a detailed description of proposed allowable maintenance/repair, including material costs and the value of the material required to replace the sign new.

Proposed Repair Material Cost	Material Cost to Replace New

SIGN OWNER/APPLICANT CERTIFICATION

I agree to abide by 75-15-101, et seq., Montana Code Annotated, and 18.6.202, et seq., Administrative Rules of Montana.

By my signature/typewritten name, I declare under penalty of perjury and the laws of the State of Montana that the foregoing is true and correct and contains no willful falsifications of misrepresentations.

Sign Owner/Applicant Signature	Date	Place of Signature (City, State)

The department will notify a permittee within 30 days of notification report receipt if maintenance or repair work appears to be noncompliant with statute or rule, and must not be commenced or completed.