Long Term Occupancy Permit - Selge Construction Co., Inc.

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Application and Permit Long Term Occupancy of City Right-of-Way Applicant: _______________________________________________________ Date: _________________ Applicant Address: ________________________________________________________________________ Project Site Address: _______________________________________________________________________ Note: Occupancy limited to street(s) immediately in front of construction site. Nature and extent of Occupancy (e.g.: proposed construction activities, equipment proposed to occupy public right-of-way, construction deliveries, etc.): ____________________________________________________________________________________ ____________________________________________________________________________________ Duration of Occupancy: ___________________________________________ Signature of Applicant: _____________________________________________ THE TERMS AND PROVISIONS OF CHAPTER 6, ARTICLE 5 and CHAPTER 18, ARTICLE 7, Sec 18-62 OF THE SOUTH BEND MUNICIPAL CODE ARE INCORPORATED HEREIN IN THEIR ENTIRETY. FAILURE TO COMPLY WITH THESE PROVISIONS SHALL RESULT IN CANCELLATON OF THIS PERMIT. THIS PERMIT SHALL BE CONDITIONED UPON THE EXECUTION AND FILING WITH THE BOARD OF PUBLIC WORKS OF A BOND IN AN AMOUNT APPROVED BY THE BOARD OF PUBLIC WORKS, CONDITIONED TO INDEMNIFY, SAVE AND KEEP HARMLESS THE CITY OF SOUTH BEND, INDIANA, FROM ANY AND ALL LOSS, EXPENSE, COST OR LIABILITY OF ANY KINDS WHATSOEVER WHICH THE CITY MAY SUFFER OR BE PUT TO FROM OR BY REASON OF ANY ACT OR THING DONE OR NEGLECT TO BE DONE, OR BY VIRTUE OF THE AUTHORITY GIVEN IN SUCH PERMIT. TO BE COMPLETED BY CITY STAFF ONLY: Bond/Fee Amount: $ _____________ Date Bond/Fee Filed: ___________________ Compliance with CH 6, ART 5 and CH18, ART 7, Sec 18-62 of the South Bend Municipal Code Fee Paid Date Issued: ___________________Issued By: __________________________________________ BOARD OF PUBLIC WORKS City of South Bend/Public Works 227 W. Jefferson Blvd South Bend, IN 46601 V 2.1 [1.15.21]June 13, 2023