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City of South Bend Public Works <br />Engineering Division <br />wX <br />227 W. Jefferson, County City Building 1316 <br />South Bend, IN 46601-1830 <br />Phone: 574.235.9251 <br />Email: rowpermitsoffice@southbendin.gov <br />TRAFFIC CONTROL AND OCCUPANCY REQUEST <br />**SUBMIT 5 WORKING DAYS MINIMUM PRIOR TO PROJECT START DATE <br />PLAN YOUR START DATE ACCORDINGLY TO AVOID DELAYS <br />Complete 1 - 5 Irlc <br />plete submittals Ca <br />t be Pr All ul rrlil�crl _r aLre <br />ocgoggngy <br />ikon ! n in; n <br />Parking Lane <br />El Travel Lane <br />1:1 <br />Full Road Closure Alley <br />1:1 <br />Sidewalk Closure <br />2 Excavation/Boring? > Requires Excavation Form Sidewalk? > Requires Sidewalk permit <br />New Approach? > Curb Cut application <br />Submission Date: _.....ITITITITIT Applicant/Company: <br />Name: <br />Phone #: <br />3 On -Site Contact:. <br />4 <br />Email Address: <br />Office <br />Cell Contractor Performing Work: <br />Phone #: <br />Office <br />Cell <br />Project STREET ADDRESS (eg: 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 />Affected Customers: ........... ..... ....._ -. -- - -- --- <br />Contractors are responsible for resolving safety issues and access concerns with affected customers - <br />ATTACH THE FOLLOWING ITEMS: 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 Checklist <br />Failure to use traffic control for traffic restrictions or closures will result in stop work orders and/or delay in permitting. <br />5 THIS OCCUPANCY PERMIT REQUEST IS NON -TRANSFERABLE .AND A SIGNATURE SUBJECTS THE NAMED CONTRACTOR/ PERMITTE E <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 <br />ENGINEERING OFFICE USE ONLY: <br />00T <br />Approved Approved as Noted F Revise Not Approved <br />Comments: <br />City of South Bend/Engineering Division Authorized Signature <br />Date: <br />Version 3.311/11/20191 <br />