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City of South Bend Public Works <br />J y.. Engineering Division <br />227 W. Jefferson, County City Building 1316 <br />South Bend, IN 46601-1830 <br />Phone: 574.235.9251 <br />Email: rowpermitsoffice@southbendin.gov <br />TRAFFIC CONTROL AND OCCUPANCYREQUEST <br />"SUBMIT 5 WORKING DAYS MINIMUM PRIOR TO PROJECT START DATE <br />PLAN YOUR START DATE ACCORDINGLY TO AVOID DELAYS <br />Complete 1 - 5 In or1 ~ e submittals cannot be rac �seci° Ails Lwrnittais re uir W occftpanc�+ f�oncl and in�i Lan0! g <br />Parking Lane Travel Lane Full Road Closure Z Alley Sidewalk Treelawn <br />2 Excavation/Boring? > Requires Excavation Form Sidewalk? > Requires Sidewalk permit <br />New Approach? > Curb Cut application <br />Submission Date„ 2/17/2020 Applicant/Company: Horizon Construction Group <br />Name: Chad Gernand Email Address: c.gernand@horizondbm.com <br />Office Phone #: 414 ) 322-1146 Horizon Construction Grou cell X Contractor Performing Work: P <br />Chad Gernand (414) 322-1146 Office <br />3 On -Site Contact: Phone #: Cell X <br />Project STREET ADDRESS (eg: 110 W. Smith RD.): 1130 South Bend Ave. South Bend, IN <br />d To): from Corby to South Bend Ave. <br />Project Location (Block limits/Streets From an <br />Y <br />e <br />... __ .., <br />**Requested Start &End 2/24i20-9/1/26 O' Requested Start & End Times: 8:00am-5:00pm <br />**Occupancy beyond 90 days" requires-completi n of Long Term Occupancy Request Application. <br />Reason for Closure: For„public ,safety and „for staging space to construct new office building on <br />property to west of north/south alley requested for closure <br />4 _... _... ..._.....-. —- __ ....... m .... ................ <br />Affected Customers, None no properties will be affected <br />Contractors are responsible for resolving safety issues and access concerns with affected customers <br />ATTACH THE FOLLOWING ITEMS: 1. Traffic Control Plan 2. Detour Plan 3. Barricades, Signs, or Flashers Placement <br />(Refer to MUTCD for Traffic Control Device Requirements) See reverse for Checklist <br />Failure to use traffic control for traffic restrictions or closures will result in stop work orders and/or delay in permitting. <br />5 THIS OCCUPANCY PERMIT REQUEST IS NON -TRANSFERABLE AND A SIGNATURE SUBJECTS THE NAMED CONTRACTOR/PERMITTEE <br />TO ALL APPLICABLE RULES, DUTIES AND OBLIGATIONS IMPOSED BY THE CITY OF SOUTH BEND MUNICIPAL CODE AND TO ALL <br />REGULATIONS IMPOSED BY THE SOUTH BEND BOARD OF PUBLIC WORKS. <br />Applicant Signature <br />ENGINEERING OFFICE USE ONLY: <br />Approved Approved as Noted <br />Comments: <br />Date <br />Revise Not Approved <br />City of South Bend/Engineering <br />Authorized Signature <br />Date: <br />Versinn 3 3 <br />