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Version 3.3 [1/11/2019] <br />**SUBMIT 5 WORKING DAYS MINIMUM PRIOR TO PROJECT START DATE <br />Parking Lane Travel Lane Full Road Closure Alley <br />Submission Date: Applicant/Company: <br />Email Address: <br />Phone #: <br /> Project STREET ADDRESS (eg: 110 W. Smith RD.): <br /> Project Location (Block limits/Streets From and To): <br />**Requested Start & End Dates:Requested Start & End Times: <br />Contractor Performing Work: <br />On-Site Contact: Phone #: <br />Reason for Closure: <br />Affected Customers:ATTACH THE FOLLOWING ITEMS: 1. Traffic Control Plan 2.Detour Plan 3. Barricades, Signs, or Flashers Placement <br />ENGINEERING OFFICE USE ONLY: <br />Approved Approved as Noted Revise Not Approved <br />Comments: ____________________________________________________________________________ <br /> _________________________________________________________________________________________ <br />City of South Bend/Engineering Division Authorized Signature Date: <br />SOUTH BEND,INDIANA 46601 TDD 574/ 235-5567 <br />Reason for Closure: <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 />PLAN YOUR START DATE ACCORDINGLY TO AVOID DELAYS <br />Complete 1 - 5 Incomplete submittals cannot be processed; All submittals require occupancy bond and insurance <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 />Office <br />Cell <br />Name: <br />Office <br />Cell <br />Excavation/Boring? > Requires Excavation Form Sidewalk? > Requires Sidewalk permit <br />New Approach? > Curb Cut application <br />1 <br />2 <br />3 <br />4 <br />5 <br />Affected Customers: <br />~ Contractors are responsible for resolving safety issues and access concerns with affected customers ~ <br />Phone: 574.235.9251 <br />TRAFFIC CONTROL AND OCCUPANCY REQUEST <br />Sidewalk <br />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 />**Occupancy beyond 90 days requires completion of Long Term Occupancy Request Application. <br />Email: rowpermitsoffice@southbendin.gov <br />Treelawn