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1 <br />> rrry City of South Bend Public Works <br />o Engineering Division <br />4227 W. Jefferson, County City Building 1316 <br />South Bend, IN 46601-1830 <br />Phone: 574.235.9251 <br />Email: dhanson@southbendin.gov <br />TRAFFIC CONTROL AND OCCUR' C "'RE'QUEST <br />*SUBMIT 5 WORKING DAYS MINIMUM PRIOR T PROJECT START DATE <br />PLAN YOUR START DATE ACCORDINGLY TO VOID DELAYS <br />CaM Iete 1 - 5 Incomplete Submittals C nnot Be Processed <br />Parking Lane \Q Travel Lane 1:1 Full Road Closur Alley Sidewalk Closure <br />2 1:1 Excavation/Boring? <br />K <br />Ell <br />Requires Excavation Form <br />Construction? > Requires Curb Cut <br />application or sidewalk permit <br />Submission Date; . IT_._.. .........._.. Applicant/Com any: <br />Name: Email Address: <br />_....... <br />Office <br />Phone #:._.____............ ............... cell Contractor erforming Work: <br />Office <br />On -Site Contact: Phone #: �. _........_ ...._ Cell <br />Project STREET ADDRESS (eg: 110 W. SmutRD.): <br />Project Location (Block limits/Streets From To): <br />Requested Start & End Dates: Requested Start & End Times: <br />Reason for Closure: <br />Affected Customers: �..,, .,. ... .... ... -_— ... <br />-- Contractors are responsible for resol dng safety issues c . c ess concerns with affected customers <br />ATTACH THE FOLLOWING ITEMS: 1. Traf c Control Plan 2. DetoursNan 3. Barricades, Signs, or Flashers Placement <br />(Refer to MUTCD for Traffic Control Device Requirements) See rev�r e for Checklist <br />Failure to use traffic control for traff restrictions or closures will result in%Jeo'�S <br />work orders and/or delay in permitting.. <br />THIS OCCUPANCY PERMIT REQUEST IS ON -TRANSFERABLE AND A SIGNATURE SUBTHE NAMED CONTRACTOR PERMITTEE <br />5 TO ALL APPLICABLE RULES, DUTIES AN OBLIGATIONS IMPOSED BY THE CITY OF SOUTH B D MUNICIPAL CODE AND TO ALL <br />REGULATIONS IMPOSED BY THE SO H BEND BOARD OF PUBLIC WORKS. <br />Applicant Signa <br />ENGINEERING OFFI E USE ONLY. <br />0 Approved Approved as Noted � Revise <br />Comments: <br />City of South Bend/Engineering) Division Authorized Signature <br />/ <br />Date <br />Not Xpproved <br />Date: <br />Version 3.2 i5/2/20181 <br />