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IN <br />City of South Bend Public Works <br />,r <br />6' Engineering Division <br />4227 W. Jefferson, County City Building 1316 <br />"uo South Bend, IN 46601-1830 <br />�a5;' <br />Phone: 574.235.9251 <br />Email: rowpermitsoffice@southbendin.gov <br />TRAFFIC CONTROL AND OCCUPANCY REQUEST <br />SUlllt IIIT 5 W01CKING DAYS MINIMUM PRIOR "iC PIII OJEC"III" S"rR"Ill' D '1E <br />P[.AIN YOUR S"iAIRF Ii ATE ACCORDINGLY10 AVOID DELAYS <br />"'"IIIu°°°°IIIIw I - S Incomplete Submittals Cannot Be Processed <br />Parking Lane Travel Lane Full Road Closure Alley Sidewalk Closure <br />Excavation/Boring? > Requires Excavation Form <br />Construction? > Requires Curb Cut <br />application or sidewalk permit <br />Submission Date: ........................ Applicant/Company: <br />Name: Email Address: <br />Offiice <br />Phone #:...... cell Contractor Performing Work: <br />i On -Site Contact: <br />Project STREET ADDRESS (eg: 110 W. Smith RD.): <br />Phone #: <br />Project Location (Block limits/Streets From and To): <br />Office <br />Cell <br />Requested Start & End Dates: ................... Requested Start & End Times: .._............. ... . <br />Reason for Closure: ............. ....._ <br />Affected Customers: <br />Confraic ors are i-esp; n�s1ble fornm�:)Mng s(:ifety ISSUE?s (.'nO c� '_(..:s ��::cnc° rn s 0h affected cu,u�w�ion�-�ers .�.�. <br />A `1A(- A THE FOLf f )WING 1T 5 1. Traffic Control Plan <br />(Refer to MUTCD for Traffic 2. Detour Plan <br />Control Device Requirements) 3. Barricades, Signs, or Flashers Placement <br />Failure to use traffic control for traffic restrictions or closures will result in <br />stop work orders and/or delay in permitting. <br />ENGINEERING OFFICE USE ONLY: <br />Approved Approved as Noted Revise <br />Comments: <br />City of South Bend/Engineering Division Authorized Signature <br />Not Approved <br />Date: <br />Version 2.1 [7/28/20171 <br />