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APPLICATION RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY The Board of Public Works must have four (4) weeks prior notice of the A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION ^^I — �N, Applicant Name: `hack( � r 4-$50�f1!( � Address: 4 r 3 (Lt�I Grtl��t. City: _SQ p rye State: TN Zip (� J Phone: �,_ ��?y) -;lvl , —(0ycx_� 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: r1 Event Name 1�~I Lxk ?C10 LL url b _..-- ix (CI ca.l bird Street Closure Name of {( Street �[ I"i rfl l ,' lA`y' _ IW TO _- Date of Event 1u►IC y 4 0 j a_ - Time Setup " 11 El start ❑a•m. L3/ End ❑a.m. Rpm. a.m. p.m. 3 PM p°' Approximate Number of Attendees Please answer the following appropriately: • This event will be open to residents outside the immediate ❑' Yes ❑ No neighborhood. • All residents on the affected block have been notified and invited. A L✓ Yes ❑ No copy of the flyer distributed is included. • This have [3/]Z event will music (live or other). Yes ❑ No • Payment of $50.00 fee payable to City of South Bend included or: Yes ❑ No • For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal ❑ Yes ❑ No Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are included with this application, and additionally N�/ filed with the Office of the City Clerk, 4ch Floor, County -City Building, 227 W. Jefferson Blvd., South Bend, Indiana. N A IF ALCOHOL IS TO BE SERVED OR SOLD / Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ Certified Check or Money Order for $400.00 must be submitted with application. ❑ • Application cannot be processed without deposit. • Deposit will be returned upon inspection of event area by the Board of Public Works, Updated 4/2013