Laserfiche WebLink
< Ulf F, <br />APPLICATION <br />" Z. <br />TO ENCROACH ONTO PUBLIC RIGHT -OF -WAX <br />THE BOARD OF PUBLIC WORKS MUST HAVE FOUR (4) WEEKS PRIOR NOTICE . <br />PLANS AND SPECIFICATIONS MUST BE ATTACHED <br />Date: / / 9 <br />Location of Encroachment: <br />PROPERTY -OWNER'S INFORMATION <br />Business/ <br />Homeowner <br />Name: ��c�r; ,��� <br />Address: .._..(-o...�mv,.._. �.---• ......- �a.......__w_. <br />City/State/Zip: mhu rs t ! C, <br />Phone qu7 U-� 7 0 / •, i II <br />Signature <br />Print Name: <br />INSTALLER'S INFORMATION <br />Business Name. <br />Address: <br />City/State/Zip:i..� <br />Attach Photo of Site <br />Here <br />(Or See Attached Photo) <br />Phone 6 5.:: i E ..Ema11._ .rwC a Vt(- <br />Signature <br />Print Name: %37o r h a mQ r k" <br />Encroachment <br />Description: L4e u!." :1� t`„u r t_ )... i .... ................ _... .��.��_... <br />Size of 1 <br />CL Road to R/W Line ... �.., _.. w. .� ._..... I" ttarr tclila7�cnt . <br />Distance of RAV 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-way. <br />Placed By: <br />This Encroachment should not be <br />relocated because <br />It has been determined that this encroachment in noway 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 />b OF 1'l.i i W )RKS APPROVAL <br />President Member Member <br />.� .._ mmra,.., .. _.. �..� ,....o.. . <br />Member Member Date <br />RETURN FORM TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 • Fax: (574) 235-9171 <br />