Review Of Permit Request Form For Warning Signs Or School Signs With Flashing Beacons & Speed Limit Feedback Signs On State Right Of Way
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2LADOTD 04.2015
Document 1
LOUISIANA DEPARTMENT OF TRANSPORTATION & DEVELOPMENT
REVIEW OF PERMIT REQUEST FORM FOR WARNING SIGNS OR SCHOOL SIGNS WITH
FLASHING BEACONS & SPEED LIMIT FEEDBACK SIGNS ON STATE RIGHT OF WAY
LOCAL GOVERNMENT OR SCHOOL INFORMATION
SELECT THE APPROPRIATE
Name _________________________________________________________________
DEVICE(S):
Mailing Address _________________________________________________________
Speed Limit Feedback Sign
City _________________________
State ____________
Zip Code ___________
Intersection Warning Sign with Flashing
Beacon
DESIGNATED GOVERNMENT/SCHOOL OFFICIAL CONTACT INFORMATION
W2-1 thru W2-8
(OWNER)
School Warning Signs
School Warning Sign with Flashing
(Submit Power of Attorney documentation stating this person has the authority to enter into a legally-
binding agreement on behalf of the local government).
Beacon
Name _________________________________________________________________
S1-1
Hands Free Zone Sign
Title __________________________________________________________________
School Speed Limit Sign with Flashing
Phone ______________________
Fax ____________________________________
Beacon
S5-1 or S4-3P, R2-,1 S4-1P
Email ________________________________________________________________
Pedestrian Crossing Sign with Flashing
Beacon
DESIGNATED CONTACT INFORMATION (if different from above)
W11-2 or W11-15
Name _________________________________________________________________
Pedestrian Pushbutton
Bike Crossing Sign with Flashing
Title __________________________________________________________________
Beacon
Phone ______________________
Fax ____________________________________
W11-1
Trucks Entering Highway Sign with
Email _________________________________________________________________
Flashing Beacon
LOCATION INFORMATION OF THE DEVICE
(DOTD owned support or breakaway support)
W8-6 or W11-10
Fire Truck Warning Sign with
City _______________________________ Parish____________________________
Flashing Beacon & preemption
Attach map with location identified along street (School Name or Intersection)
W11-8
Other ________________________
____________________________)
State Route _____________________________
(___
Sizes:
Latitude_________________________ Longitude _________________________
36 X 36
48 X 48
____________________________)
State Route _____________________________
(___
24 X 48
Latitude_________________________ Longitude _________________________
36 X 72
Colors:
____________________________)
State Route _____________________________
(___
Yellow
Latitude_________________________ Longitude _________________________
Fluorescent Yellow Green
____________________________)
State Route _____________________________
(___
Hands Free Zone plaque:
Rectangular, retroreflective white sign with a
Latitude_________________________ Longitude _________________________
black border and black letters
24 inches in width and 12 inches in height
____________________________)
State Route _____________________________
(___
“HANDS FREE ZONE” printed in black on
Latitude_________________________ Longitude _________________________
two lines
Letters are 3 inches in height and use the
____________________________)
State Route _____________________________
(___
Clearview Hwy2-w font
Installed below the SCHOOL SPEED LIMIT
Latitude_________________________ Longitude _________________________
sign
(If more than 6 locations, attach additional sheets.)
ATTACH THE FOLLOWING:
1.
A map illustrating where the sign(s) will be placed
2.
Manufacturer’s specifications for flashing beacons or feedback sign
Construction Plans including exact location, height, electrical (if applicable),
3.
foundation and breakaway support
For bicycle warning sign, attach adopted bicycle path plan
4.
Documentation of school vouchers
5.
I certify that the information contained herein is true, complete, and correct to the best of my knowledge. I understand that
if any information contained herein is found to be falsified, this request and any permit issued based on this information shall
be voided.
Signature of Owner ____________________________________________
Date ______________________
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