Laserfiche WebLink
APPLICATION <br />To ENCROACH ONTO PUBLIC RIGHT-OF-WAY <br />THE BOARD OF PUBLIC WORKS MUST IIAVI,-- FOUR (4) WEEKS PRIOR NO'rICE <br />ADate: PLANS AND SPECIFS M ICATIONUST BE ATTACHED a7 )F <br />Location of Encroachment:, 6 13 <br />PROPERTY -OWNER'S INFORMATION <br />Business/ <br />Homeowner <br />Name: wt <br />Address: <br />AD-13 iorn 814. <br />f, I I <br />City/State/Zip: �0 ljj� Besll Cis <br />Phone F A <br />.mail -�_arj[A <br />Signature Attach Photo of Site <br />K_ Here <br />Print Name: A & "4 (Or See Attached Photo) <br />INSTALLER'S INFOftMATION <br />Business Narne: <br />.6 Vj 164's- <br />Address: I R-31 3 r 1) 54-_ <br />A4111� <br />City/State/Zip: ()Ice 0A q( L J_ <br />Phone 6 7 t5'106Email CQ64am am <br />Signature <br />`",Print Name: <br />Encroachment <br />Description: kwn i rAA 141 eqAf ().f <br />0 <br />CL Road to R <br />/W Line Size of <br />Encroachment <br />A <br />Distance of R/W <br />Amount in R/W <br />The above iiifoririatiola is to the best of my lctiowledge accurate and correct with regard to he en <br />croachment the City,sright- <br />of-way. <br />Placed By: Y1 <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 it is <br />recommended that the encroachment be permitted to remain. <br />t11RDO Ll WO IDS APPROVAL <br />Presiden Member M ber <br />b 6 '201 v <br />Member Member 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: (5 74) 23 5 -9251 0 Fax: (574) 23 5 -9171 <br />