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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: 6 �dL ede, Z 74 <br />Address: kzlf -lZ 0-4/7x,, <br />City/State/Zip:1,3�GyArt' <br />Phone: sT?Z;��'p �y�0 Email: <br />IENCROACHMENT INFORMATION: <br />Location of Encroachment: 24 37f3� s% lyh��l,�.�r11 <br />Encroachment Description: <br />CL Road to RAM Line: Size of Encroachment: z/ 7� <br />Distance of R/W: �' Amount in R/W: J' ? <br />INSTALLER'S INFORMATION: <br />Business Name: <br />Address: <br />City/State/Zip: <br />Phone: <br />Signature: <br />Printed Name: <br />mail: <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />RrPhotos of the area where encroachment will take place. <br />Z'Plans and Specifications <br />I�'J 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: <br />Printed Name of Applicant: <br />