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Instructions: 1) Print Clearly 2) Complete All Sections <br />Submit: 1) This Form In Person 2) Or Email To: rowpermitsoffice@southbendin.gov <br />3)Upon Permit approval: Sign issued permit and Return <br /> **Contractor is responsible for associating their company Project # with CSB Permit # for invoicing** <br />Incomplete Submittals Cannot Be Processed <br />Applicant <br />(Contractor/Company Name) <br />Contact Name Email <br />Phone Number <br />Street Address | Location of Work <br />Electric FiberCable <br />Water <br />In Street <br />Sanitary Sewer <br />GasType of Work <br /> Outside curb, but in treelawn/sidewalk Right of Way <br />Date | Duration of project (eg: 2/1/18, 2 hrs) <br />City of South Bend Public Works <br />Engineering Division <br />227 W. Jefferson, County City Building 1316 <br />South Bend, IN 46601-1830 <br />Phone: 574.235.9254 <br />Excavation Permit Request <br />Excavation in ROW without a permit will result in stop work order and/or delays in permitting. <br />Emergency excavations must be phoned into the Permit Office no later than NOON the following day. <br />Date Submitted: <br />Comments | Description of Work <br />Cut Location <br />Boring# Cuts <br />Other _______________ <br />Trenching (open) # FeetType of Cut <br />Manhole repair <br />v 4.3.19 <br />Applicant Signature Date <br />THIS EXCAVATION 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 />EXCELLENCE | ACCOUNTABILITY | INNOVATION | INCLUSION | EMPOWERMENT <br />1316 County-City Building | 227 W. Jefferson Blvd. | South Bend, Indiana 46601 | 574.235.9251. | www.southbendin.gov