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ENCROACHMENT APPLICATION <br />City of South Bend - Board of Public Works <br />r. c. T7 <br />227 W . Jefferson Boulevard, Ste.1316 <br />South Bend, IN 46601 <br />PROPERTY OWNER INFORMATION: <br />Name of Business/Homeowner: Sliver Phone Services LLC <br />Address: 1608 Southwood Drive <br />City/State/Zip: Mishawaka IN 46544 <br />Phone:574-315-9205 Email: kierracooper344@gmail.com <br />ENCROACHMENT INFORMATION: <br />Location of Encroachment: 224 E.Monroe Street South Bend IN, 46601 <br />Encroachment Description: Public Payphone <br />CL Road to R/W Line: 25 ft <br />Distance of R/W: <br />12ft3in <br />INSTALLER'S INFORMATION: <br />Business Name: Kierra Cooper <br />Address: 1608 Southwood Drive <br />Size of Encroachment: 10in x 16in <br />Amount in R/W: 5 ft <br />City/State/zip: Mishawaka IN 46544 <br />Phone:574-315-9205 Email: kierracooper344@gmail.com <br />Signature: <br />Printed Name: Kierra Cooper <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: (P __ ZJ W2_3 <br />Printed Name of Applicant: Kierra Cooper <br />