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APPLICATION <br />TO ENCROACH ONTO PUBLIC RIGHT-OF-WAY <br />THE BOARD OF PUBLIC WORKS MUST HAVE FOUR (4) WEEKS PRIOR NOTICE <br />PLANS AND SPECIFICATIONS MUST BE ATTACHED <br />Date: 8/10/2016 <br />Location ofEncroaclvnent: r �U �� rar' � �D�P-T+ <br />a0LO R 0 P,114 s %"IF <br />PROPERTY -OWNER'S INFORMATION <br />Business Nanu:...p �Cm.V i'�L L� <br />Address: L �, •Z��6f`401, 1 ?y i G`l <br />City/State/Zip; �Lh. �ytA, tom{ f�1, �� <br />signature <br />Print Name: <br />INSTALLER'S INFORMATION <br />Business Name: <br />anadco Inc_ <br />Address: 10625 State Road 10 <br />Citylstate2ip: OS 46501 <br />Signature <br />PrintName: <br />Encroachment <br />Description: <br />CL Road to R/w Line <br />Distance of R/W <br />yll U94tp , <br />Attach Photo of site <br />Here <br />(Or See Attached Photo) <br />It <br />The above information is to the best of my knowledge accurate and correct with regard to the encroachment in the City's right -of. <br />way. <br />Placed By; <br />This Encroachment should not <br />relocated because <br />It has been determined that this encroachment in no way impairs the highway or with the fi•ee and safe flow of traffic thereon, and <br />it is recommended that the encroachment be permitted to remain. <br />OARD OF PUBLIC WO CS APPROVAL <br />-� -- <br />Presid tt ember Member <br />Member —— <br />Member Date <br />RETURN FORM TO: <br />Board of Public Works <br />1316 Comity -City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 • Fax; (574) 235-9171 0 E-Mail: publicwkQrbsouthbendin.gov <br />