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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: YMCA of Michiana <br />Address: 111 W Jefferson Blvd <br />City/State/Zip: South Bend IN 46601 <br />Phone: 574-298-3991 <br />Email: mbeckman@ymcagm.org <br />ENCROACHMENT INFORMATION: <br />Location of Encroachment: Corner of Business US 31 (Main St) and Jefferson Blvd <br />Encroachment Description: Blade sign mounted to the side of the YMCA <br />CL Road to R/W Line: us 31 Bus (Main St) / Jefferson Blvd Size of Encroachment: 46" <br />Distance of R/W: 20' <br />INSTALLER'S INFORMATION: <br />Business Name: Hayes Design Co <br />Address: 1247 Mishawaka Ave <br />City/State/Zip: South Bend, IN 46615 <br />Phone: 574-236-5615 Email <br />Signature: iffLIADIU <br />Printed Name: Dana Baker <br />Amount in R/W: 46" <br />dbaker@hayesdco.com <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 safeflowof traffic thereon and may be revoked at any time. <br />![ GL- Date: 6-20-24 <br />Signature of Applicant:. <br />Printed Name of Applicant: Dana Baker <br />