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ry <br />ENCROACHMENT APPLICATION <br />City of South Bend - Board of Public Works <br />•'e 227 W . Jefferson Boulevard, Ste. 1316 <br />" South Bend, IN 46601 <br />PROPERTY OWNER INFORMATION: <br />Name of Business/Homeowner: i Li l SX�Cdk,� rr 1 <br />Address: L!0_1 _ D k0_k6E PRIL <br />City/State/Zip: f^ -r fU) 1 _V <br />Phone:',--)- 7_� - 9CA(= 331}44 Email: <br />ENCROACHMENT INFORMATION: <br />Location of Encroachment: S? Qnd �_ACk X3Tpcln 7N Q, Ne, <br />Encroachment Description: P_nC__ C),X-\d 37FE'9 <br />CL Road to R/W Line: JU:L _Size of Encroachment: ^ 5hj�d <br />Distance of R/W: LOO -JPC-,�A' Amount in R/W: a f6 t <br />INSTALLER'S <br />Business Name: <br />Address: "U <br />City/State/Zip <br />Phone:'.� ■Y <br />Signature: _ ]4 <br />Printed Name: I <br />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: J <br />Printed Name of Applicant: <br />J) <br />