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TRAFFIC CONTROL AND OCCUPANCY REQUEST <br />City of South Bend - Division of Engineering <br />227 W Jefferson Boulevard, Ste 1316 <br />4 = South Bend, IN 46601 <br />APPLICANT INFORMATION <br />Name of Contractor/Company: 44,401.aL..•rrr�dGTi a,.� <br />Name of Applicant: lii <br />Phone:��-9�.f-�'f�.�-� Email Address: �2r7� cr7 �a��d� • Go'`� <br />On -Site Contact: Phone: 3/.2- 22/ 9330 <br />PROJECT INFORMATION <br />Requested Dates (mm/dd/yyyy): 9 / 15' /20 A 3 to -s 1 I 120 z 4 <br />Time of Work: .4's to .�'.�o &A4 <br />Location of Work: ❑ Entire Street ❑ Travel Lane ❑ Parking Lane <br />'Sidewalk ❑ Tree Lawn ❑ Alley <br />Type of Work: ❑ Excavation/Boring (Also requires Excavation Form) <br />"ew Drive Approach (Also requires Curb Cut Application)(TE„/o'^gAy) <br />I'Sidewa I k <br />Address of Project: . �'� � �+^� S� J -VA .c4cmll, :EW .`�.��o0 <br />Project Boundaries: r ,14c. Al. $.ve1 W r1 — �✓. i`1vi:� ,r <br />Description of Work: cif <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />i�Traffic control plan including detour map and traffic devices <br />❑ Communication (letter, door hanger, signs, etc.) to affected property owners <br />Failure to use traffic control for traffic restrictions or closures will result in stop work <br />orders and/or delay in permitting. This Occupancy Permit Request is non -transferable. A <br />signature subjects the named contractor/permittee to all applicable rules, duties and <br />obligations imposed by the South Bend Municipal Code and to all regulations imposed by <br />the City's Board of Public Works. <br />Signature of Applicant: Date: ��'-� -? <br />Applications should be dropped off to the City's Engineering Office or emailed to <br />rowpermitsoffice[?southbendin.gov. For questions, contact Tara Bussell at 574.235.9254. <br />OFFICE USE ONLY: <br />Date Received: Fee Paid: <br />Approval Date: <br />