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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: Northern Indiana Historical Society, Inc. <br />Address: 808 West Washington Street <br />City/State/Zip: <br />South Bend, IN 46601 <br />Phone:574-235-9664 ext 226 Email: bharding@historymuseumSB.org <br />ENCROACHMENT INFORMATION: <br />100 Block of South Chapin, West Side 41.67fi131432937794 N,-86.26159864557135 W <br />Location of Encroachment: <br />Encroachment Description: State Historical Marker <br />CL Road to R/W Line: <br />Distance <br />INSTALLER'S INFORMATION: <br />Business Name: <br />Size of Encroachment: <br />Amount in R/W: <br />Northern Indiana Historial Society, Inc. <br />Address: 808 West Washington Street <br />City/State/Zip: South Bend, IN 46601 <br />Phone:574-235-96 <br />Signature: <br />Printed Name: Brla <br />ext 226 Email: bharding@historymusuemSB <br />.org <br />ardi <br />utive Director <br />INCLUDE THE FOLLOWING+TCyIvIS WITH YOUR APPLICATION: <br />Photos of the area where encroachment wi I I take place. <br />Plans and Specifications <br />l 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 tr�ffi <br />c thereon and may be revoked at any time. <br />Signature of Applicant: —� <br />Printed Name of Applicant: <br />4/27/2023 <br />Date: <br />