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ENCROACHMENT APPLICATION <br />City of South Bend – Board of Public Works <br />227 W . Jefferson Boulevard, Ste. 1316 <br />South Bend, IN 46601 <br />PROPERTY OWNER INFORMATION: <br />Name of Business/Homeowner: ______________________________________________________________ <br />Address: _______________________________________________________________________________________ <br />City/State/Zip: _________________________________________________________________________________ <br />Phone:______________________________ Email: ____________________________________________________ <br />ENCROACHMENT INFORMATION: <br />Location of Encroachment: ___________________________________________________________________ <br />Encroachment Description: ___________________________________________________________________ <br />CL Road to R/W Line: _________________________________ Size of Encroachment:________________ <br />Distance of R/W: _____________________________________ Amount in R/W: ______________________ <br />INSTALLER'S INFORMATION: <br />Business Name: ________________________________________________________________________________ <br />Address: _______________________________________________________________________________________ <br />City/State/Zip: _________________________________________________________________________________ <br />Phone:______________________________ Email: ____________________________________________________ <br />Signature: ____Shannon Reidenbach <br />__________________________________________________________________________________ Printed <br />Name: _________________________________________________________________________________ INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />Photos of the area where encroachment will take place. <br />Plans and Specifications <br />Completed Agreement <br />AFFIRMATION <br />I, the undersigned do hereby certify and affirm that all the information given in this <br />application is accurate and correct. I understand that encroachments must in no way impair <br />the highway or free and safe flow of traffic thereon and may be revoked at any time. <br />Signature of Applicant: Date: <br />Printed Name of Applicant: ____________________________________________________________________