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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 />p , i PLANS AND SPECIFICATIONS MUST BE ATTACHED <br />Date: 1 T Location of Encroachment: S Q 9 Poor k, A\j T V e- <br />eei13Y1 <br />PROPERTY -OWNER'S INFORMATION <br />Business Name: <br />Address: <br />City/State/Zip: <br />Signature <br />Print Name: (- *�-t,-Ey �C U L-[- / 0%/V 1,1ZMC'f1 j <br />IN/STALLER^INFORMATION <br />Business Name: C" /rY /aF S0�-/ pp <br />Address: I316 Cuv)t ^61f f ui )d)✓1 <br />City/State/Zip: Q a 7 �0. 5'e ' er5a e 1 ,q , <br />5oc: L cUr l /IV44 <br />Signature <br />Print Name: <br />4fn <br />Attach Photo of Site <br />Here <br />(Or See Attached Photo) <br />Encroachment A� <br />Description: /"!Lit"kC_(rV 1 j �Y1C�{G�JCQ 17/I?b iCo 1 J?L)j�/&CcU MCQrkiY)Size of k1 C� <br />itCL Road to R/W Line I r m L0_w a3? / jC '� / Encroachmentst�j <br />Distance ofR/W C.� J '�b aorb AmounlinR/W o�5�i7 �C58 <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 be <br />relocated because <br />It has been determined that this encroachment.ir-a�pairs the highway or with the free and safe flow of traffic thereon <br />it is recommended that the encroachment be permitted to remain.CA <br />BOARD OF PUBL WO APPROVA J <br />President Mcmb9f Member <br />Member Member Date <br />RETURN FORM TO: <br />Board of Public Works <br />1316 County-0ity Building <br />227 Wert. Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 6 Fax: (574) 235-9171 • E-Mail: publicwks@southbendin.gov <br />