Laserfiche WebLink
City of South Bend Public Works Phone: 574.235.9251 <br />Engineering Division ov Email: dhonson@southbendin.gov <br />227 W. Jefferson, County City Building 1316 g <br />South Bend, IN 46601-1830 <br />TRAFFIC CONTROL AND OCCUPANCYRE'QUE'ST <br />"SUB 11T 5 WORKING II AYS M111NIMUM PRIOR "I" l:'1110TECT TAIR"I" IDA"I"IE <br />PI....AN YOUR SIARI. DATE ACC OR[)IINGI....Y F0 AVC: 11'..) DELAYS <br />Comlplete 1111 5 Incomplete Submittals Cannot Be Processed <br />11 Parking Lane Travel Lane 1:1 Full Road Closure 1:1 Alley 1:1 Sidewalk Closure <br />Excavation/Boring? > Requires Excavation Form Sidewalk? > Requires Sidewalk permit <br />New Approach? > Curb Cut application <br />Submission Date: Applicant/Company: <br />Name: Email Address: <br />Office <br />Phone #: Cell Contractor Performing Work: <br />On -Site Contact: Phone #: office <br />Cell <br />Project STREET ADDRESS (s°:f: 1 10 W. Smith RD.): <br />Project Location (Block limits/Streets From and To): <br />"Requested Start & End Dates: Requested Start & End Times: <br />**Occupancy beyond 90 days requires completion of Long Term Occupancy Request Application. <br />Reason for Closure: <br />in <br />Affected Customers: <br />Cry <br /><afrn "'wsp s A..)de NoN,.r�I',,M,Doq ving.Y(.)fE,'qy Ms 1uE:�s an G„,1 aQ„,. Qm.0. �ss concerns with Qm,%ff(�0.>NG""Q,,,.N Q,„. C.o a'Dq orn er'a'V ..,. <br />Al iA( H "'Iifs" FC'"N. L0 WINGITEMS: 1. Traffic Control Plan 2. Detour Plan 3. Barricades, Signs, or Flashers Placement <br />(Refer to MUTCD for Traffic Control Device Requirements) See' reverse for (::'f1ueckff,sf <br />Failure to use traffic control for traffic restrictions or closures will result in stop work orders and/or delay in permitting. <br />THIS OCCUPANCY PERMIT REQUEST IS NON -TRANSFERABLE AND A SIGNATURE SUBJECTS THE NAMED CONTRACTOR/PERMITTEE <br />TO ALL APPLICABLE RULES, DUTIES AND OBLIGATIONS IMPOSED BY THE CITY OF SOUTH BEND MUNICIPAL CODE AND TO ALL <br />REGULATIONS IMPOSED BY THE SOUTH BEND BOARD OF PUBLIC WORKS. <br />Applicant Signature Date <br />ENGINEERING OFFICE USE ONLY: <br />Approved Approved as Noted Revise Not Approved <br />Comments: <br />City of South Bend/Engineering Division Authorized Signature Date: <br />Version 3.3 [1/11/2019] <br />