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5Ul Lff � <br />1�/_ - EXCAVATION PERMIT REQUEST <br />City of South Bend - Division of Engineering <br />iWf P.A1, <br />x\ Wa 227 W Jefferson Boulevard, Ste 1316 <br />South Bend, IN 46601 <br />FAPPLICANT INFORMATION <br />Name of Contractor/Company: <br />[aITOY=l <br />PROJECT INFORMATION <br />Date of Work (mm/dd/yyyy): <br />Time of Work: <br />Location of Work Address: <br />Email Address: <br />/ /20 to <br />to <br />Type of Work: ❑ Cable ❑ Electric ❑ Fiber ❑ Gas ❑ Manhole repair <br />❑ Sanitary Sewer ❑ Water ❑ Other <br />Type of Cut: Number of Cuts ❑ Boring ❑Trenching <br />Cut Location: ❑ In Street ❑ Tree lawn/sidewalk right-of-way <br />Description of Work: <br />/20 <br />Excavation in right-of-way WITHOUT a permit will result in a stop work order and/or <br />delays in permitting. Emergency excavations must be called into the Permits Office at <br />574.235.9254 no later than noon the following day. <br />This excavation permit request is non-transferrable. A signature subjects the named <br />contractor/permittee to all applicable rules, duties and obligations imposed by the City of <br />South Bend Municipal Code and to all regulations imposed by the City of South Bend's <br />Board of Public Works. <br />Signature of Applicant: <br />Date: <br />Completed application should be dropped off to the City's Engineering Office or emailed <br />to rowpermitsoffice@south bend in.gov. For questions, contact the Permits Manager at <br />574.235.9254. <br />OFFICE USE ONLY. <br />Date Received: Fee Paid: Approval Date: <br />