Laserfiche WebLink
�- ENCROACHMENT APPLICATION <br />Ti J <br />�- City of South Bend - Board of Public Works <br />227 W . Jefferson Boulevard, Ste.1316 <br />. " Y South Bend, IN 46601 <br />PROPERTY OWNER INFORMATION: <br />Name of Business/Homeowner: Van;r±LLe. 4 e1 + <br />Address: 141 J S !✓ 1,4 s-x!!e a ve <br />City/State/Zip: 13eno- S `/ Ll 6�; 17 <br />Phone: f -7-!- ?o q - 46 9S Email: 4�e + S* c> aQ i,`e!!e c. ! nmo,4 - Cob <br />ENCROACHMENT INFORMATION: <br />Location of Encroachment: _Trey L,, C-c�a •f- of d.S !=' L aS4Ile <br />Encroachment Description: E`-i��e C=re� L.'�,r n,r 'c, "e --Tee <br />CL Road to R/W Line: Tree lct.w,4 ,,s co0afi14 rw&-�e Size of Encroachment: on Qt 3 <br />h e�o Is P 0.$4- <br />Distance of R/W: w0"i v 054 a d4ic� -yM snde�/kAmount in R/W: X"V2' <br />INSTALLER'S INFORMATION: <br />Business Name: Y),,.feCle ke &4- <br />Address: t; /tea -411e AL.,,,e- <br />City/State/Zip: �oe,„d ZP q (a 6/ i <br />Phone: 5741- 343 Email: ���.`S F'c�a�PeG/�� u ma./1. co rn. <br />Signature:4, <br />Printed Name: VJa tWi e Yeer`s 4- <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />C"Photos of the area where encroachment will take place. <br />I�Plans and Specifications <br />13"tompleted 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 noway impair <br />the highway or free and safe flow of traffic thereon and may be revoked at any time. <br />Signature of Applicant: �a„""L Date: <br />Printed Name of Applicant: U 4wfe6[e 1�e4s+ _ <br />