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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: I f ` •1 6 - ..qd <br />Location of Encroachment: 215 Eaa� SY(Aowre S , Al <br />PROPERTY -OWNER'S INFORMATION <br />Business Name: <br />,Soak " sksiA61%Ie T)eVaulpw%en+ <br />LL <br />Address: <br />1101 Eas{ calfc le St Jr- 264 <br />City/State/Zip: <br />&,Jk Den <br />Attach Photo of Site <br />Signature <br />�1./�-- <br />Here <br />Print Name: <br />VEL.VQ-r C*W404 <br />(Or See Attached Photo) <br />INSTALLER'S INFORMATION <br />Business Name: <br />MATTR WS 1-Ljr- <br />Address: <br />401 Fe,$l Wy t st,i _ 20� <br />City/State/Zip: <br />Spg =/N-44G11 <br />Signature <br />Print Name: <br />`,�-i�/'� <br />yeAY4 Ckmeake, <br />Encroachment <br />Description: <br />aN pYC Tint. ales, 1%,4 nerd <br />AaA A i%a <br />ilaeetwn.ar.A►}ii <br />641tll %n«; * x <br />CL Road to R/W <br />Line % <br />Size of <br />Encroachment <br />u <br />$ pit P; <br />Distance of R/W <br />of , <br />Amount in R/W <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 <br />relocated because <br />It has been determined that this encroachment in no way impairs the highway or with the free and safe flow of traffic thereon, and <br />it is recommended that the encroachment be permitted to remain. <br />�dMn BOARD OF PUBLIC WORKS APPROVAL <br />President Member Medber <br />Member Member <br />Date <br />RETURN FORM TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 9 Fax: (574) 235-9171 a E-Mail: publieNvks@southbendiii.gov <br />2 <br />