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ENCROACHMENT APPLICATION <br />f� City of South Bend - Board of Public Works <br />227 W . Jefferson Boulevard, Ste. 1316 <br />2865 <br />South Bend, IN 46601 <br />PROPERTY OWNER INFORMATION: <br />Name of Business/Homeowner: <br />Address: 701 W Sample St <br />South Bend PD <br />City/State/Zip: South Bend, Indiana 46601 <br />Phone: Email: <br />ENCROACHMENT INFORMATION: <br />Location of Encroachment: Multiple Locations <br />Encroachment Description: Attachment of license plate reading camera to existing poles_ <br />CL Road to R/W Line: <br />Distance of R/W: <br />INSTALLER'S INFORMATION: <br />Size of Encroachment: <br />Amount in R/W: <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 />❑ 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 safe few of traffic thereon and may be revoked at any time. <br />Signature of Applicant:Lz4t�-�" ` Date: 05/05/2025 <br />Printed Name of Applicant: Christine Strileckis <br />