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APPLICATION <br />To ENCROACH ONTO PUBLIC RIGHT-OF-WAY ( a <br />THE BOARD OF PUBLIC WORKS MUST HAVE FOUR (4) WEEKS PRIOR NOTICE <br />PLANS AND SPECIFICATIONS MUST BE ATTACHED <br />IS6 ,- <br />Date: 11/5/19 <br />Location of Encroachment: 115 S..:...Lafayette Blvd.. _y,,m................................................m. <br />PROPERTY -OWNER'S INFORMATION <br />Business/ <br />Homeowner <br />Name: City of South Bend <br />Address: 227 W. Jefferson Blvd. — Suite 1400S <br />City/State/Zip: South Bend, IN 46601 <br />Phone 574-235-5814 mail ctltt swel ea�soutl L cndin. oym .. <br />E <br />Signature ." <br />Print Name: —_t... <br />INSTALLER'S INFORMATION <br />Business Name: Citv of South Bend <br />Address: 227 W. Jefferson Blvd. — Suite 1400S <br />City/State/Zip: South Bend, IN 46601 <br />Phone <br />Signature <br />Print Name: <br />Encroachment <br />Description: <br />574-235-5847 Email cdressel southbendin.Rov <br />Indiana State Historical Marker <br />CL Road to R/W Line S. Lafayette Blvd. <br />Distance of R/W 15' <br />Attach Photo of Site <br />Here <br />(Or See Attached Photo) <br />Size of 3.5' <br />Encroachment <br />3.5' <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: City of South Bend <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 />ARD O t LIC` APPROVAL <br />F1 estden t Member <br />Member <br />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 />