Fillable Form 1: TRAFFIC CONTROL AND OCCUPANCY REQUEST 2 (City of South Bend)

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Form 1: TRAFFIC CONTROL AND OCCUPANCY REQUEST 2 (City of South Bend)

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Version 3.3 [1/11/2019]
**SUBMIT 5 WORKING DAYS MINIMUM PRIOR TO PROJECT START DATE
Parking Lane
Travel Lane Full Road Closure
Alley
Submission Date:
Applicant/Company:
Email Address:
Phone #:
Project STREET ADDRESS (eg: 110 W. Smith RD.):
Project Location (Block limits/Streets From and To):
**Requested Start & End Dates:
Requested Start & End Times:
Contractor Performing Work:
On-Site Contact:
Phone #:
Reason for Closure:
Affected Customers:
ATTACH THE FOLLOWING ITEMS:
1. Traffic Control Plan
2. Detour Plan
3. Barricades, Signs, or Flashers Placement
ENGINEERING OFFICE USE ONLY:
Approved Approved as Noted Revise Not Approved
Comments: ____________________________________________________________________________
_________________________________________________________________________________________
City of South Bend/Engineering Division Authorized Signature
Date:
SOUTH BEND, INDIANA 46601
TDD 574/ 235-5567
Reason for Closure:
City of South Bend Public Works
Engineering Division
227 W. Jefferson, County City Building 1316
South Bend, IN 46601-1830
PLAN YOUR START DATE ACCORDINGLY TO AVOID DELAYS
Complete 1 - 5 Incomplete submittals cannot be processed; All submittals require occupancy bond and insurance
(Refer to MUTCD for Traffic Control Device Requirements) See reverse for Checklist
Failure to use traffic control for traffic restrictions or closures will result in stop work orders and/or delay in permitting.
Office
Cell
Name:
Office
Cell
Excavation/Boring? > Requires Excavation Form
Sidewalk? > Requires Sidewalk permit
New Approach? > Curb Cut application
1
2
3
4
5
Affected Customers:
~ Contractors are responsible for resolving safety issues and access concerns with affected customers ~
Phone: 574.235.9251
TRAFFIC CONTROL AND OCCUPANCY REQUEST
Sidewalk
THIS OCCUPANCY 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.
Applicant Signature _______________________________
Date ________________
**Occupancy beyond 90 days requires completion of Long Term Occupancy Request Application.
Email
: rowpermitsoffice@southbendin.gov
Treelawn
TRAFFIC CONTROL CHECKLIST
PURPOSE: SAFETY FOR MOTORISTS, BICYCLISTS, PEDESTRIANS, WORKERS, EMERGENCY
AND ENFORCEMENT PERSONNEL AND EQUIPMENT
• Submit Traffic Control with any Occupancy Request in the City of South Bend.
• Maps shall follow MUTCD Traffic Control Device guidelines, but do not submit
MUTCD examples as your traffic control.
INCLUDE THE FOLLOWING:
Street map showing CURRENT street status
~ Can show aerial or streets only
Street names
Striping and sidewalks
North Arrow
Location of Activity Area and placement of vehicles and equipment in
the work space
Location of manholes or other facilities within work space
Barricades, signs and/or flasher placement
Taper distance/Advanced warning signage
Traffic detour plan
Examples of simple traffic control:
North
North
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Form 1: TRAFFIC CONTROL AND OCCUPANCY REQUEST 2 (City of South Bend)

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Completed 16 July 2020

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