Highway Entrance Permit Application

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TE-4 Form
HIGHWAY ENTRANCE PERMIT APPLICATION
(Please type or print)
PERMIT NO.______________________
Office Use Only
DATE:____________________
PROPERTY OWNER INFORMATION
CONTRACTOR / DEVELOPER INFORMATION
Name, as shown on deed
Name
Mailing Address:____________________________________
Mailing Address:____________________________________
Daytime Phone:_____________________________________
Daytime Phone:______________________________________
LOCATION (If unknown leave blank)
State Route________________
US Route_____________________
Log Mile________________
County_____________________________
City / Town___________________________________
Posted Speed Limit________________
Pavement width________________ Shoulder width_________
Right-of-way width_______________________
Property frontage width_________________________
Reasons for requesting permit______________________________________________________________
(Continue on back if necessary)
I, _____________________________, understand that a change in use of the permitted driveway will require a
new permit.
________________________________________________
Signature
(Owner/Owner Designee)
____Residential
____Commercial
____Government Agency
(Designation as defined in Section 2 of the Manual for Constructing Driveway Entrances on State Highways)

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