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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 />�\ PLANS AND SPECIFICATIONS MUST BE ATTACHED <br />Date: <br />o O <br />Location of Encroachment: <br />k <br />PROPERTY -OWNER'" I�NFC)RMA"I" ON <br />Business/ <br />Homeowner <br />Name: <br />> <br />Address:w <br />_m <br />City/State/Zip„ <br />Phone <br />Signature <br />tti. <br />Print Name: <br />� <br />-- <br />INST. LLER'S INFORMATION <br />Business Name:x <br />Address:�0��._.. <br />City/State/Zip: <br />i <br />Phone <br />Signature <br />Print Name: <br />Encroachment <br />Description: <br />CL Road to R/W Line <br />Distance of R/W <br />Attach Photo of Site <br />Here <br />(Or See Attached Photo) <br />Size of <br />Encroachment <br />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 no way 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 />Member <br />BOARD OF P L,1(7" Um <br />S APPROVAL <br />D <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 • Fax: (574) 235-9171 <br />Date <br />