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�/'TRAFFIC CONTROL AND OCCUPANCY REQUEST <br />City of South Bend - Division of Engineering <br />l' y 227 W .Jefferson Boulevard, Ste 1316 <br />'a South Bend, IN 46601 <br />APPLICANT INFORMATION <br />Name of Contractor/Company: <br />Name of Applicant: <br />Phone: <br />On -Site Contact: <br />PROJECT INFORMATION <br />Requested Dates (mm/dd/yyyy): <br />Time of Work: <br />Email Address: <br />Phone: <br />/ /20 to <br />to <br />/20 <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 />❑ New Drive Approach (Also requires Curb Cut Application) <br />❑ Sidewalk <br />Address of Project: <br />Project Boundaries: <br />Description of Work: <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />❑ 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: <br />Date: <br />Applications should be dropped off to the City's Engineering Office or emailed to <br />rowpermitsoffice@south bend in.gov. For questions, contact Tara Bussell at 574.235.9254. <br />OFFICE USE ONLY. <br />Date Received: Fee Paid: Approval Date: <br />