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To ENCROACH ONTO PUBLIC RIGHT-OF-WAY <br />THE BOARD OF PUBLIC WORKS MUST HAVE FOUR (4) WEEKS PRIOR NOTICE <br />Date: <br />Location of Encroachment: / 70.2 Al. Z:1: we.1 -' / <br />PROPERTY -OWNER'S INFORMATION <br />Business Name: <br />Address: <br />City/State/Zip: <br />Signature <br />Print Name: <br />Business Name: <br />S7Y Address: <br />302 26s� <br />City/State/Zip: <br />Signature <br />Print Name: <br />Encroachment <br />Description: <br />INSTALLER'S INFORMATION <br />St2d rt' -4e- Polol'yi-�bvl <br />Cl/? k('VeeY-Si0(8 2A, <br />lhdJavta g('51'06'1; &at-lfe-y' <br />Size of �����//� / <br />CL Road to R/W Line Encroachment 9" �rifD(�PJsP1i Can �l-t-r <br />Distance ofR/W <br />The above information is to the best of my knowlec <br />way. 4-11 Of - O[,t` A <br />Placed By: <br />This Encroachment should not be <br />relocated because <br />Amount in R/W <br />accurate and correct with regard to�� the encroachment <br />BGlcat /S �.Ef1'j4 _ L � m SI<. <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 />X /h-t10ARD S APPROVAL <br />t� AV <br />P IC � <br />President Member Me er <br />) cl!�-- <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 9 E-Mail: publicwks@southbendin.gov <br />