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ok°All ENCROACHMENT APPLICATION <br />'d� City of South Bend - Board of Public Works <br />r.,' 227 W. Jefferson Boulevard, Ste. 1316 <br />max. 1865k South Bend, IN 46601 <br />PROPERTYOWNER INFORMATION: <br />Name of Business/Homeowner: <br />South Bend PD <br />Address: 701 W Sample Street <br />City/state/zip: South Bend, IN 46601 <br />Phone:470-568-4561 Email: dskibins@southbendin.gov <br />ENCROACHMENT INFORMATION: <br />Location of Encroachment: Multiple Locations <br />Encroachment Description: _Attachment to existing poles <br />CL Road to R/W Line: <br />Size of Encroachment: <br />Distance of R/W: Amount in R/W: <br />INSTALLER'S INFORMATION: <br />Business Name: Flock Group Inc DBA Flock Safety <br />Address: 1170 Howell Mill Rd Ste 210 <br />City/State/Zip: _Atlanta, GA 30318 <br />Phone:470-568-4561 Email: christine.strileckis@flocksafety.com <br />Signature: _ <br />Printed Name: Christine Strileckis <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />0 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 noway impair <br />the highway or free and safe flow of traffic thereon and maybe revoked at anytime. <br />Signature of Applicant: ���'Y "Y, , 1/' Date: <br />11 /07/2024 <br />Printed Name of Applicant: -Christine Strileckis <br />