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APPLICATION <br />To ENCROACH ONTO PUBLIC RIGHT-OF-WAY <br />Tl-m BOARD OF PUBLIC WORKS MUSTI IAVE FOUR (4) WErKS ['R [OR No,l,fcj, <br />/ � PLANS AND SPECIF [CATIONS MuCHL S'I'BE A,r'l'AI) <br />Date: 21 <br />I � - <br />Location of Firicroachment: VA-,3-V (V (6616? <br />P ItTV-1)WNER'S INI- VT� ON'13 <br />Business/ <br />Homeowner <br />Name: 6 Q` <br />Address: j- �o r <br />City/State/Zip: <br />Phone Email <br />Signature <br />Print Name: <br />Business N ame: <br />Address: <br />City/State/Zip; <br />Phone <br />Signature <br />Print Name: <br />Encroachment <br />Description: <br />INSTAL1,ER'S INFORMATION <br />43,4 -1 Email ;> i <br />64, <br />(N d <br />CL Road to R/W Line <br />Di e static of RIW <br />Ir-) <br />M <br />Ic )GA, <br />A� ec cl o <br />Size of <br />Encroachment _Y7 LN-, qh- <br />. . ......... <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 -MY <br />Placed By: r-)C- <br />This Encroachment should not be <br />relocated because o 4- VL) k k ( be 0 (-Jo a, <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 />President <br />Member <br />BOARD OF PUBLIC WORKS APPROVAL <br />Member <br />Member <br />RETURN FORM TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefkrson Boulevard <br />South Mid, IN 46601 <br />Phone: (574) 235-9251 o F= (574) 235-9171 <br />Member <br />Date <br />