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x1n 4i <br />AI,P1,ICKI'10N <br />ININ�,kn, <br />p "I'llk <br />To ENGROACR ONTO PUBLICRIGIU-01`-WAY <br />TI.ILBOAftDOVPtJBI,I(,WOIZI�',SMI,JSTI-IAVr,FouR.(4)�WF,EK',3P[UORNOIII(IlL <br />,ioNs Mus,r BF,, ArrACHF-,J) <br />I S AND SIMCIFICKI <br />P -AN <br />DaW: <br />Looation ofEncroachmeat: <br />PR0PEyrry-oWTqER)S INFORMATION <br />Bodiless/ <br />Homeowner S-C A() Dow ra,5 <br />Name: <br />Address: <br />city/statc/zip� _aQAh_. 6e DO k4 U& 17 <br />Phone <br />Signature <br />Print Name� <br />INSTALLER'S INFORMA,rm <br />Business Milne: -F <br />_reovpt,� <br />Address: <br />�_w <br />City/State/Zip: <br />Pholle 594- M/—;QV,,?V Email <br />Signature <br />Print Name: J,D LN <br />Microaoliment <br />Desoriptiorl: &wk �iqrds� <br />N <br />fS t <br />A to <br />photo) <br />SiZe Of <br />CLRoadtoR/WUne 11croachment <br />C. <br />Distance, of RAV ------ Amount it] kv <br />Tho above inrormation is to the best of my knowledge a0mirateand correct With rc�aard to the encroachment fil, the City's_d_g_h_t_-of_-wRy, <br />Placed By: <br />relocated because <br />I'llis, Encroachment shoda <br />i <br />It has been detm-mined that this encroacillijellt ill 110 way ill,pair-s-_ <br />recommended that the encroachment be perml(ted. to remaill, the highway or willi the frecand sare flow of traffic thercon, arld it is <br />S APPROVAL <br />pr S i ent ember <br />16 - <br />42 <br />M 11 er <br />Member Date <br />RETURN F0164TO; <br />Bonrd of Publio Works <br />1316 County -City Building <br />Weqt Jeffic"on8oulsvavd <br />South Band, IN 46601 <br />Phone: (574) 2,35-9251 a FaM (574) 235-9171 <br />