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SpU n g <br />�4 \ ENCROACHMENT APPLICATION <br />City of South Bend - Board of Public Works <br />227 W. Jefferson Boulevard, Ste. 1316 <br />x x <br />1865 South Bend, IN 46601 <br />PROPERTY OWNER INFORMATION: <br />Name of Business/Homeowner: 4w/ <br />Address: <br />City/Stat( <br />Phone:?SZ32 Email: T <br />IENCROACHMENT INFORMATION: <br />Location of Encroachment: <br />Encroachment Description: <br />CL Road to R/W Line: Size of Encroachment: ! <br />Distance of R/W: /CGl/� G�i 62/1 Amount in R/W: 1 <br />INSTALLER'S INFORMATION: <br />Business Name: / 11;ne.O <br />Address: 74 / /V • WildwocJ <br />City/State/Zip: <br />Phone: <br />Signature: <br />'A <br />Printed Name: <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />o4n Photos of the area where encroachment will take place. <br />.B'rlans and Specifications <br />,Ptompleted 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 flovy of traffic t ereon and maybe revoked at anytime. <br />/ n �1 <br />Signature of Applicant: ! &)M C t CON Date: / Z <br />Printed Name of Applicant: j, <br />L4P- <br />n <br />