Office of Outdoor Advertising
Ten Park Plaza, Room 6133
Boston, MA 02116-3969
Telephone: (857) 368-9700
http://www.mass.gov/massdot/ooa
NOTICE OF SURRENDER OF PERMIT(S)
FOR OUTDOOR ADVERTISING
Per 700 C.M.R. 3.16 (3) Permitholder hereby notifies the OOA of the surrender, cancellation, or
relinquishment of permit(s).
PLEASE PRINT OR TYPE:
1)
Permitholder Name:
Principal Business Address: (Street address must be included)
City/Town
State
Zip
Contact: ( Name & Title)
Telephone #:
Fax #:
Email:
The undersigned warrants and represents that he/she is duly authorized to sign this documen t.
Authorized Signature:
Date:
Please provide notification via certified mail to the property owner and city/town where the sign is located of
your intent to surrender the permit(s). This notification should be sent to the property owner and the city/town
prior to submitting this Notice of Surrender to the Office of Outdoor Advertising.
REVISED: ejf/leq, 8/6/2015
Page 1 of 2
Permit Surrender
2)
Please specify each permit; for surrenders of more than 20 permits, please attach permit data
in a table format listing all requested information.
See attached
3)
TOTAL NUMBER OF PERMITS SURRENDERED
Permit(s)
(Permit Street Address)
(Municipality)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
REVISED: jrr/leq, 8/6/2015
Page 2 of 2
Permit Surrender
Please submit all pages of application: incomplete applications will not be processed.