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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 />1 l r �� PLANS AND SPECIFICATIONS MUST BE ATTACHED <br />Date; IV r t, <br />Location of Encro <br />PR <br />Business/ <br />Homeowner <br />Name: <br />Address: <br />City/State/Zip: <br />Phone <br />Signature <br />Print Name: <br />Business Name: <br />Address: <br />City/State/Zip: <br />Phone 5 79' <br />Signature <br />Print Name: <br />Encroachment <br />Description: <br />CL Road to RIW Line <br />Distance of RJW <br />l_��a rnS <br />SI1 wgqk11'5 694 <br />Size of <br />Encroachment <br />Amount in R/W <br />7r ball(,,. <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: Gv- L^_ <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 />BOARD OF PUBLIC WORKS <br />Gary A. Gil., President `' <br />"nd_ <br />Elisabeth A. Maredik, Member <br />BOARD OF PUBLIC WORKS APPROVAL <br />Jordan V. Gathers, Member <br />Joseph R. Molnar, Member <br />ATTEST: <br />0I(_ <br />Linda M.Martin,Clerk 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 />December 17, 2020 <br />Date <br />