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o SOUTH&' City of South Bend Public Works Phone: 574.235.9251 <br />Engineering Division <br />�.� Email: dhanson@sotrthbendrn.gov <br />. „ e 4227 W. Jefferson, County City Building 1316 <br />J!1. F, South Bend, IN 46601-1830 <br />7 <br />,x x, <br />1865 <br />TRAFFIC CONTROL, AND OCCUPANCYREQUEST <br />"SUBMIT 5 WORKING DAYS MINIMUM PRIOR TO PROJECT START DAVE <br />PLAN YOUR START DATE ACCORDINGLY TO AVOID DELAYS <br />Complete 1 - 5 Incomplete Submittals Cannon Be Processed <br />❑ Parking Lane ❑ Travel Lane ❑ Full Road Closure ❑ Alley ❑ Sidewalk Closure <br />2 ❑ Excavation/Boring? > Requires Excavation Form ❑ Construction? > Requires Curb Cut <br />application or sidewalk permit <br />4 <br />Submission Date: <br />Name: — <br />Phone #: <br />On -Site Contact: <br />Applicant/Company: <br />Email Address: <br />Office <br />Cell Contractor Performing Work: <br />Project STREET ADDRESS (eq. 1 10 W. Smith RD.): <br />Phone #: <br />Project Location (Block limits/Streets From and To): <br />Requested Start & End Dates: <br />Reason for Closure: <br />Requested Start & End Times: <br />Office <br />Cell <br />Affected Customers: <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) <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 Date <br />ENGINEERING OFFICE USE ONLY: <br />❑ Approved <br />Comments: <br />❑ Approved as Noted ❑ Revise ❑ Not Approved <br />City of South Bend/Engineering Division Authorized Signature <br />Date: <br />Version 3.1 [10/24/20171 <br />