Application For Encroachment Permit - Kentucky Transportation Cabinet
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4Kentucky Transportation Cabinet
TC 99‐1 (A)
1/2015
Department of Highways
Page 1 of 4
Permits Branch
APPLICATION FOR ENCROACHMENT PERMIT
Permittee Information
KYTC No.
Permit Information
Name
Address
Address
City
City
State
Zip
State
Zip
County
Mile‐
Phone#
Route No.
Point
Contact
Longitude (X)
Latitude (Y)
Phone
Cell
Email
Information below to be filled out by KYTC
Contact
Air Right
Entrance
Phone
Cell
Utilities
Other:
Email
Left
Right
X‐ing
Access:
Full
Partial
by Permit
General Description of Work:
THE UNDERSIGNED PERMITTEE(s) (being duly authorized representative(s) or owner(s)) DO AGREE TO ALL TERMS AND CONDITIONS ON THE
TC 99‐1 (A).
Signature
Date
This is not a permit unless and until the permittee(s) receives an approved TC 99‐1(B) from KYTC. This application shall become
void if not approved by the cancellation date. The cancellation date shall be one year from the date the permittee submits their
application.
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