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ENCROACHMENT APPLICATION <br />'yCity of South Bend - Board of Public Works <br />R'; <br />.., 227 W . Jefferson Boulevard, Ste.1316 <br />South Bend, IN 46601 <br />PROPERTYOWNER INFORMATION: <br />Name of Business/Homeowner: <br />Pyna I Cit 10 . f v; .,; J If i <br />Address Z 3 EdSEwca�c� ��' <br />City/State/Zip: Sovml 9 Lib I6 <br />i t <br />Phone:s)Y-31q-t9?7<p Email: f#7rucle f©yi" icr C 51no-i <br />ENCROACHMENT INFORMATION: <br />Location of Encroachment: L 36' F d 1 rz Lze0l Art. S-r -rN �F- � •► �jl(�(� <br />Encroachment Description: t pdf-'f — 12x 2 I n 18Y Z <br />CL Road to R/W Line: L19 rT" o P Size of Encroachment: I z 2L <br />x 1 v-z ��X I <br />Distance of R/W: O PS R / %,i Amount in R/W: j <br />INSTALLER'S INFORMATION: <br />Business Name: '-j IA - <br />Address: <br />City/State/Zip: <br />Phone: Email: <br />Signature: <br />Printed Name: <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: C <br />Photos of the area where encroachment will take place. <br />0"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 />�� 10 • � � � <br />Signature of Applicant:���� Date: i f <br />Printed Name of Applicant: <br />RECEIVED <br />JUL 11 2024 <br />"ify of bourn benu <br />D?V rtf Pam ^ <br />