Gouvernement du Québec PERMIT
Ministère To be used for advertising panels
des Transports placed front-to-back or angle-wise
(s. 1)
________________________________________
This application must be made | À l’usage du ministère des Transports |
simultaneously with or | Année Région District N° séq |
subsequently to an application for | |
a single-panel permit |________________________________________|
APPLICATION FOR PERMIT
1. Identification of the person responsible for the advertising panel
_________________________________________________________________________________
| Surname First name Telephone No |
| |
|_________________________________________________________________________________|
| Firm name (in the case of a legal person) |
| |
|_________________________________________________________________________________|
| Address of main establishment Postal code |
| |
|_________________________________________________________________________________|
| In the case of a legal person, indicate Telephone No |
| the name of a director |
|_________________________________________________________________________________|
2. Description of the advertising panel
_________________________________________________________________________________
| Dimensions of the panel Total height of advertising sign |
| (from top of panel to ground) |
| Height: m Width: m Height: m |
|_________________________________________________________________________________|
| For any structure placed 60 m or more from a highway, identify |
| the architect or engineer who made the plan |
| |
| Name Plan No Date |
|_________________________________________________________________________________|
3. Location
_________________________________________________________________________________
| Route Direction Distance from |
| edge of roadway |
| |
| metres |
|_________________________________________________________________________________|
| Cadastre No Municipality |
| |
|_________________________________________________________________________________|
| Name and address of landowner Telephone No |
| |
|_________________________________________________________________________________|
| À l’usage du Route Tronçon Section Chaînage Direction (sens) |
| ministère des |
| Transports -» |
|_________________________________________________________________________________|
4. Term of permit
_________________________________________________________________________________
| The term of the permit must correspond Where this permit application is |
| to the time remaining in the term of made subsequently to the |
| the single-panel permit application for a single-panel |
| permit, the fees will be |
| proportional to the time remaining |
| in the term of that permit |
| |
| ( ) 1 year ( ) 3 years ( ) 5 years Fees exigible: $ |
|_________________________________________________________________________________|
5. Preliminary authorizations
_________________________________________________________________________________
| Not required Required Included |
| |
| Municipality ( ) ( ) ( ) |
| |
| Commission de protection |
| du territoire agricole ( ) ( ) ( ) |
|_________________________________________________________________________________|
I certify that the information provided is complete and true and I am aware
that a false statement may result in my application being denied or my permit
being cancelled without compensation or refund of fees. I further recognize
that the signing of this form constitutes a permit application within the
meaning of section 1 of the Regulation respecting roadside advertising
(chapter P-44, r. 1).
________________________________________________________________________________
Name of signatory in block letters Signature Date
(In the case of a
legal person, the
signature of the person
authorized by resolution
to make the application)
________________________________________________________________________________
| |
| À l’usage du ministère des Transports |
| Chef de district |
| Je recommande la délivrance du permis _______________________________________ |
| Signature Date |
|________________________________________________________________________________|
DÉLIVRANCE DU PERMIS
autorisant l’installation du Que ce permis soit demandé en même temps
panneau publicitaire ou à une date ultérieure du permis
pour panneau recto seulement, le numéro
(À l’usage du ministère et la date d’échéance de ce dernier
des Transports) doivent toujours être spécifiés
_________________________________________________________________________________
| Panneau en "V" ou au verso d’un | Panneau recto seulement |
| autre panneau | |
| | |
| N° de permis | |
| du panneau _________________________| N° du permis _________________________ |
| | |
| Date d’échéance | |
| du permis __________________________| Date d’échéance ______________________ |
| | |
| Le panneau publicitaire doit être | |
| installé dans les 6 mois suivant | Période de |
| la délivrance du permis | validité ( )1 an ( )3 ans ( )5 ans |
|_____________________________________|___________________________________________|
_________________________________________________
Directeur régional Date