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08 1712:23p P. 1 <br />APPLICATION <br />To ENCROACH ONTO PUBLIC RIG11717 Or. -WAY <br />THE BOARD OF PUBLIC WORKS MUST HAVE FOUR (4) WEEKS PluopNOTIC.E <br />PLANS AND SPECIFICATIONS MIDST BE ATTACHED <br />Date- -7 <br />Location of Encroachment: �096/ � Iq I Qy-Aco,4t_;4- 14LA� <br />PROPERTY -OWNER'S INFORMATION <br />'R <br />Business Name: <br />Address: <br />City/statclzip. /A/ 46Iz5_ <br />Attach Photo of Site <br />Signature Here <br />Print Name: (Or See Attached Photo) <br />INSTALLERS ITNFOR?4ATION <br />Address: <br />City/State/Zip: j C_ / L�g :0 /A/ <br />Signature <br />Print Nanau: <br />Encroachment <br />Description: <br />P- r 29LO-1-22 /3 U .11, D 160'64 <br />Size of <br />CL Road to R. Line %30 Encroachmenu 4 <br />Distance of R[W 0 Amount in R/W 2 <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 13y: <br />This Encroachment should not be <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 />BOARD OF PUBLIC WORKS APPROVAL <br />Z— <br />Presider Me her Member <br />/'ember <br />Member <br />RET-URN FORM TO: <br />Board of Public Works <br />1316 Couay-City Building <br />227 West Jefferson Boulevard <br />Soutb Bend, IN 46601 <br />Phone: (574) 235-9251 * rax: (574) 235-9171 <br />Date <br />OA <br />