Non Res Block Party - South Bend Chapter Indiana Black Expo

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APPLICATION FOR USE OF, AND BLOCKING OF ACCESS TO, THE PUBLIC RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES l he Board of Public Works must have FOUR (4) weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, T BE INCLUDED WITH APPLICATION. nI Fee Paid 1 Applicant Name: South Indiana Black Address: P.O.335 City: South Bend State: Indiana Zip: 466 Phone: 574-360-2202 This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name Back to School Rally Location (Describe Area/Route) Street Closure Name of Street Orange Street From Bridsell To College Street Date of Event Augustst 19, 2016 20 _ 8:00 ❑ a.m. ❑ a.m. Time: Registration/Setup am Start 9:00 ❑ p.m. End 12:00 ❑ P.M. Approximate Number of Attendees 200 Answer the following appropriately: 1. This event will have music (live or other). ® Yes ❑ No a. I understand the Noise Ordinance described in the Agreement/Permit ® Yes ❑ No 2. Required Information to Accompany Application a. Certified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are included with this application, and Yes ❑ No additionally filed with the Office of the City Clerk, 4a' Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana. c. Certificate of Insurance d. Maps, drawings of the area and setup plan Yes ❑ No 3. a. This event involves City streets Yes ❑ No b. This event involves County roads ❑ Yes ❑ No c. This event involves State highways ❑ Yes ❑ No d. This event involves the use of the sidewalk ❑ Yes ❑ No Updated 4/2015 1