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APPLICATION <br />TO ENCROACH ONTO PUBLIC RIGHT-OF-WAY <br />THE BOARD OF PUBLIC WORKS MUST HAVE FOUR (4) WEEKS PRIOR NOTICE <br />5. µ PLANS AND SPECIFICATIONS MUST BE ATTACHED <br />,//lDate: <br />Location of Encroachment:. �,. „J 1 0_-i� �" � (',1A_e <br />PROPERTY -OWNER'S INFORMATION <br />Business/,, <br />Homeowner <br />Name: <br />Address: <br />City/State/Zip: _ A-.�,. 0,Y6A <br />Phone 4GI► Email ";Y Signature <br />/I T944;m� <br />Y� <br />Print Name: <br />J <br />INSTALLER'S INFOATION <br />Business Name: ." ti °3 � Y e ' A 0 <br />C � __ ._ . . <br />Address: 2 �) Id OA2j �_& K <br />City/State/Zip: �&OA6 TjQ Lif,&m <br />Phone <br />Signature <br />_w <br />7� Email �/ g <br />Print Name: _ f _11�b L <br />Encroachment <br />Description: <br />CL Road to R/W Line <br />Distance of R/W <br />/f <br />The above information is to the best of my knowledge accurate and <br />Placed By: <br />This Encroachment should not be <br />relocated because <br />�a�ir °a•it ���. <br />s <br />rrt�� <br />Size of �p h <br />l;ncroachmcn a � to [ N . IFC <br />Amount in R/W .,-71 . 1�o n <br />with regard to the encroachment in the City's right-of-way. <br />It has been determined that this encroachment in no way impai 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 />OARD OF P A LCUOKSAPPROVAL <br />President Member Member <br />Member Member <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 0 Fax: (574) 235-9171 <br />,//.-)- a 9 <br />Da e <br />