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City of South Bend/Public Works <br />227 W. Jefferson Blvd <br />South Bend, IN 46601 <br />Application and Permit <br />Long Term Occupancy of City Right -of -Way <br />Applicant: <br />Date: 9-/-to2 3 <br />Applicant Address: 47 �;A. A.►a .��:c ,�I� �;,,{� �.,� IA/ 4(o / <br />Project Site Address: A. rYfc V'rA <br />Note: Occupancy limited to street(s) immediately in front of construction site. <br />Nature and extent of Occupancy (e.g.: proposed construction activities, equipment proposed <br />to occupy public right-of-way, construction deliveries, etc.): <br />Duration of Occupancy: 2&Vz <br />Signature of Applicant: <br />THE TERMS AND PROVISIONS OF CHAPTER 6, ARTICLE 5 and CHAPTER 18, ARTICLE 7, Sec 18-62 OF THE <br />SOUTH BEND MUNICIPAL CODE ARE INCORPORATED HEREIN IN THEIR ENTIRETY. FAILURE TO COMPLY <br />WITH THESE PROVISIONS SHALL RESULT IN CANCELLATON OF THIS PERMIT. <br />THIS PERMIT SHALL BE CONDITIONED UPON THE EXECUTION AND FILING WITH THE BOARD OF PUBLIC <br />WORKS OF A BOND IN AN AMOUNT APPROVED BY THE BOARD OF PUBLIC WORKS, CONDITIONED TO <br />INDEMNIFY, SAVE AND KEEP HARMLESS THE CITY OF SOUTH BEND, INDIANA, FROM ANY AND ALL LOSS, <br />EXPENSE, COST OR LIABILITY OF ANY KINDS WHATSOEVER WHICH THE CITY MAY SUFFER OR BE PUT TO <br />FROM OR BY REASON OF ANY ACT OR THING DONE OR NEGLECT TO BE DONE, OR BY VIRTUE OF THE <br />AUTHORITY GIVEN IN SUCH PERMIT. <br />TO BE COMPLETED BY CITY STAFF ONLY: <br />Bond/Fee Amount: $ Date Bond/Fee Filed: <br />Compliance with CH 6, ART 5 and CHI 8, ART 7, Sec 18-62 of the South Bend Municipal Code <br />Fee Paid <br />Date Issued: <br />BOARD OF PUBLIC WORKS <br />President <br />Member <br />Issued By: <br />Member <br />Member <br />V 2.1 [1.15.211 <br />