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140)('1 f ff f City of South Bend Public Works Phone: 574.235.9251 <br />16 Engineering Division <br />Email: dhanson@southbendi <br />ii,�A4' 4227 W. Jefferson, County City Building 1316 <br />n.gov <br />South Bend, IN 46601-1830 <br />TRAFFIC CONTROL AND OCCUPANCY REQUEST <br />"SUBMIT 5 WORKING DAYS MINIMUM PRIOR TO PROJECT START DATE <br />PLAN YOUR START DATE ACCORDINGLY TO AVOID DELAYS <br />Complete 1 - 5 Incomplete Submittals Cannot Be Processed <br />1 Parking Lane E Travel Lane 1:1 Full Road Closure Alley 1:1 Sidewalk Closure <br />2 F-] Excavation/Boring? > Requires Excavation Form Construction? > Requires Curb Cut <br />application or sidewalk permit <br />Submission Date: December 11, r 18 Applicant/Company: G y <br />Name: <br />Phone #: <br />3 On -Site Contact: <br />Email Address: <br />Office <br />Cell Contractor Performing Work: <br />Project STREET ADDRESS (eg: 1 10 W. Smith RD.): <br />Phone #: <br />Project Location (Block limits/Streets From and To): <br />Requested Start & End Dates: TBD <br />Office <br />CeR <br />Requested Start & End Times: TBD <br />Reason for Closure: _ ._._.__. .... ...... .,_-------- -----------.................................... - <br />4 __.................. .................... .................. ___. <br />Affected Customers;" ... .......... ..... <br />Contractors are responsible for resolving safety issues and access concerns with affected customers - <br />ATTACH THE FOLLOWING ITEMS: 1. Traffic Control Plan 2. Detour Plan 3. Barricades, Signs, or Flashers Placement <br />(Refer to MUTCD for Traffic Control Device Requirements) <br />Failure to use traffic control for traffic restrictions or closures will result in stop work orders and/or delay in permitting. <br />5 THIS OCCUPANCY PERMIT REQUEST IS !NO7N-TRANSFERISLE AND A SIGNATU ' 'BJECTS THE NAMED CONTRACTOR/PERMITTEE <br />TO ALL APPLICABLE RULES, DUTIES ANPOSED BY TH ITY F' S UTH BEND MUNICIPAL CODE AND TO ALL <br />REGULATIONS IMPOSED BY THE SOUTH PUBLIC OR S.Applicant Signature Date December 11, 2018 <br />Marshall, Pre ent <br />ENGINEERING OFFICE USE ONLY: <br />11 Approved Approved as Noted Revise Not Approved <br />Comments: <br />City of South Bend/Engineering Division Authorized Signature Date: <br />Version 3.1 [10/24/20171 <br />