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z, ti5pU1 tt jj�;y <br />APPLICATION <br />TO ENCROACH ONTO PUBLIC RIGHT-OF-WAY <br />THE BOARD OF PUBLIC WORKS MUST HAVE FOUR (4) WEEKS PRIOR NOTICE, <br />PLANS AND SPECIFICATIONS MUST BE ATTACHED <br />,rk{s <br />Date: July 10, 2017 <br />Location of Encroachment: t¢ ,� [/ n <br />'. ` ` <br />,PROPERTY -OWNER'S INFORMATION <br />Business PE <br />Name: t t'1n i P:5 <br />Address: 233 South Main Street <br />City/State/Zip: South Bend, lndialia 46601 <br />C Attach Photo of Site <br />Signature - -a' w _ Here <br />Print Name; <br />(Oj• See Attached Photo) <br />INSTALLER'S INFORMATION <br />Business Name: Custom Awnhi <br />Address: 1251 Third Street <br />CityiState/zip: O ceola, Indiana 46561 <br />Signature ZJIM jLA <br />Print Name: <br />Encroachment <br />Description: <br />CL Road to R/W Line <br />Distance of Rt W <br />Beals <br />Caims Entrance Cann y <br />Size of <br />`3 Encroachment Z <br />Amount in R/ W 2 <br />The above inibrmation is to the best oimy knowledge accurate and correct with regard to the encroachment in tite City's right-of- <br />way. <br />Placed By: <br />This Encroachment should not be <br />reloc-ted because <br />It has been determined that this encroachment in no way impairs the highway or with the free and safe flow of traffic thereon, and <br />it is recommended that the encroachment be permitted to remain. <br />APPROVt1L <br />President Member ember <br />Member �^ <br />Member <br />Date <br />RETURN FORN•I TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jcl'rerson Botilevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 v Fa;x: (574) 235-9171 o L•:-Mail: ptiblictvks@sotitl)bendin.gov <br />2 <br />