HomeMy WebLinkAboutLong Term Occupancy Permit - Elwood Ave. 2021Application and Permit
Long Term Occupancy of City Right-of-Way
Applicant: _______________________________________________________ Date: _________________
Applicant Address: ________________________________________________________________________
Project Site Address: _______________________________________________________________________
Note: Occupancy limited to street(s) immediately in front of construction site.
Nature and extent of Occupancy (e.g.: proposed construction activities, equipment proposed
to occupy public right-of-way, construction deliveries, etc.):
____________________________________________________________________________________
____________________________________________________________________________________
Duration of Occupancy: ___________________________________________
Signature of Applicant: _____________________________________________
THE TERMS AND PROVISIONS OF CHAPTER 6, ARTICLE 5 and CHAPTER 18, ARTICLE 7, Sec 18-62 OF THE
SOUTH BEND MUNICIPAL CODE ARE INCORPORATED HEREIN IN THEIR ENTIRETY. FAILURE TO COMPLY
WITH THESE PROVISIONS SHALL RESULT IN CANCELLATON OF THIS PERMIT.
THIS PERMIT SHALL BE CONDITIONED UPON THE EXECUTION AND FILING WITH THE BOARD OF PUBLIC
WORKS OF A BOND IN AN AMOUNT APPROVED BY THE BOARD OF PUBLIC WORKS, CONDITIONED TO
INDEMNIFY, SAVE AND KEEP HARMLESS THE CITY OF SOUTH BEND, INDIANA, FROM ANY AND ALL LOSS,
EXPENSE, COST OR LIABILITY OF ANY KINDS WHATSOEVER WHICH THE CITY MAY SUFFER OR BE PUT TO
FROM OR BY REASON OF ANY ACT OR THING DONE OR NEGLECT TO BE DONE, OR BY VIRTUE OF THE
AUTHORITY GIVEN IN SUCH PERMIT.
TO BE COMPLETED BY CITY STAFF ONLY:
Bond/Fee Amount: $ _____________ Date Bond/Fee Filed: ___________________
Compliance with CH 6, ART 5 and CH18, ART 7, Sec 18-62 of the South Bend Municipal Code
Fee Paid
Date Issued: ___________________Issued By: __________________________________________
BOARD OF PUBLIC WORKS
___________________________________________
President
___________________________________________
Member
___________________________________________
Member
___________________________________________
Member
City of South Bend/Public Works
227 W. Jefferson Blvd
South Bend, IN 46601
V 1.11.19
January 26, 2021
DocuSign Envelope ID: 86675F1C-CAB9-4079-94D8-645F00CAE043DocuSign Envelope ID: FDADED50-75A9-497B-AE56-0678682F5CB5
DocuSign Envelope ID: 86675F1C-CAB9-4079-94D8-645F00CAE043DocuSign Envelope ID: FDADED50-75A9-497B-AE56-0678682F5CB5
DocuSign Envelope ID: 86675F1C-CAB9-4079-94D8-645F00CAE043DocuSign Envelope ID: FDADED50-75A9-497B-AE56-0678682F5CB5
DocuSign Envelope ID: 86675F1C-CAB9-4079-94D8-645F00CAE043DocuSign Envelope ID: FDADED50-75A9-497B-AE56-0678682F5CB5
October 27, 2020
Occupancy Permit No.: 4447
CITY OF SOUTH BEND PETE BUTTIGIEG, M AYOR
DEPARTMENT OF PUBLIC W ORKS D EPARTMENT OF PUBLIC WORKS
Date Issued:6/12/2020
Exp 7/12/2020
Address
1200 Elwood Avenue
Contractor Name AEP
Contractor Phone (574) 232-2091
Inspector Matt Longfellow
Inspector Phone (574) 286-9589IssuerLAH
Comments Travel lane/Parking/Alley/Sidewalk restrictions - Elwood from
Portage to Kessler- 08/24 to 11/24 - Installation of electric
transmission system
OFFICE OF THE CITY ENGINEER, South Bend, Indiana certifies that the above contractor, having an
approved occupancy bond on file with the Board of Public Works is granted a permit to occupy the City
Right of Way in front of the above address under Provisions of the South Bend Municipal Code Chapter 18.
THIS OCCUPANCY PERMIT IS NON-TRANSFERABLE AND ITS ISSUANCE SUBJECTS THE NAMED
CONTRACTOR/PERMITTEE TO ALL APPLICABLE RULES, DUTIES AND OBLIGATIONS IMPOSED BY
THE CITY OF SOUTH BEND MUNICIPAL CODE AND TO ALL REGULATIONS IMPOSED BY THE SOUTH
BEND BOARD OF PUBLIC WORKS.
VOID AFTER 90 DAYS. GREATER THAN 90 DAYS REQUIRES BOARD OF PUBLIC WORKS APPROVAL.
Contractor Signature
Printed Name
Amount $4,500.00
Payment Type Check
Paid by Check No.:6048
Start Date 6/12/2020