Fillable Excavation Permit Request (City of South Bend)

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Excavation Permit Request (City of South Bend)

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The Excavation Permit Request (City of South Bend) form is 2 pages long and contains:

  • 1 signature
  • 12 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of South Bend

BROWSE CITY OF SOUTH BEND (IN) FORMS

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Instructions: 1) Print Clearly 2) Complete All Sections
Submit: 1) This Form In Person 2) Or Email To: rowpermitsoffice@southbendin.gov
3) Upon Permit approval: Sign issued permit and Return
**Contractor is responsible for associating their company Project # with CSB Permit # for invoicing**
Incomplete Submittals Cannot Be Processed
Applicant
(Contractor/Company Name)
Contact Name Email
Phone Number
Street Address | Location of Work
Electric
Fiber
Cable
Water
In Street
Sanitary Sewer
Gas
Type of Work
Outside curb, but in treelawn/sidewalk Right of Way
Date | Duration of project
(eg: 2/1/18, 2 hrs)
City of South Bend Public Works
Engineering Division
227 W. Jefferson, County City Building 1316
South Bend, IN 46601-1830
Phone: 574.235.9254
Excavation Permit Request
Excavation in ROW without a permit will result in stop work order and/or delays in permitting.
Emergency excavations must be phoned into the Permit Office no later than NOON the following day.
Date Submitted:
Comments | Description of Work
Cut Location
Boring
# Cuts
Other _______________
Trenching (open)
#
F
eet
Type of Cut
Manhole repair
v 4.3.19
Applicant Signature
Date
THIS EXCAVATION PERMIT REQUEST IS NON-TRANSFERABLE AND A SIGNATURE SUBJECTS THE NAMED CONTRACTOR/PERMITTEE
TO ALL APPLICABLE RULES, DUTIES AND OBLIGATIONS IMPOSED BY THE CITY OF SOUTH BEND MUNICIPAL CODE AND TO ALL
REGULATIONS IMPOSED BY THE SOUTH BEND BOARD OF PUBLIC WORKS.
EXCELLENCE | ACCOUNTABILITY | INNOVATION | INCLUSION | EMPOWERMENT
1316 County-City Building | 227 W. Jefferson Blvd. | South Bend, Indiana 46601 | 574.235.9251. | www.southbendin.gov
click to sign
signature
click to edit
List All Other Contractors
(Contractor/Company Name)
1
st
Subcontractor
Contact Name
Email
Phone Number
(Contractor/Company Name)
2
nd
Subcontractor
Contact Name
Email
Phone Number
(Contractor/Company Name)
3
rd
Subcontractor
Contact Name
Email
Phone Number
(Contractor/Company Name)
4
th
Subcontractor
Contact Name
Email
Phone Number
Excavation Permit Request
EXCELLENCE | ACCOUNTABILITY | INNOVATION | INCLUSION | EMPOWERMENT
1316 County-City Building | 227 W. Jefferson Blvd. | South Bend, Indiana 46601 | 574.235.9251. | www.southbendin.gov
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Excavation Permit Request (City of South Bend)

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Completed 16 July 2020

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