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EXCAVATION PERMIT REQUEST <br /> City of South Bend – Division of Engineering <br /> 227 W Jefferson Boulevard, Ste 1316 <br /> South Bend, IN 46601 <br />Name of Contractor/Company: <br />Phone: Email Address: <br />Date of Work (mm/dd/yyyy): _______ /_______ /20_______ to _______ /_______ /20_______ <br />Time of Work: _____________________ to ____________________ <br />Location of Work Address: <br />Type of Work:  Cable  Electric  Fiber  Gas  Manhole repair <br />Sanitary Sewer  Water  Other <br />Type of Cut: Number of Cuts Boring Trenching <br />Cut Location:  In Street  Tree lawn/sidewalk right-of-way <br />Description of Work: <br />Excavation in right-of-way WITHOUT a permit will result in a stop work order and/or <br />delays in permitting. Emergency excavations must be called into the Permits Office at <br />574.235.9254 no later than noon the following day. <br />This excavation permit request is non-transferrable. A signature subjects the named <br />contractor/permittee to all applicable rules, duties and obligations imposed by the City of <br />South Bend Municipal Code and to all regulations imposed by the City of South Bend’s <br />Board of Public Works. <br />Signature of Applicant: Date: <br />Completed application should be dropped off to the City’s Engineering Office or emailed <br />to rowpermitsoffice@southbendin.gov. For questions, contact the Permits Manager at <br />574.235.9254. <br />APPLICANT INFORMATION <br />PROJECT INFORMATION <br />OFFICE USE ONLY: <br />Date Received: Fee Paid: Approval Date: