Laserfiche WebLink
(� APPLICATION <br />FOR THE USE OF, AND BLOCKING OF, ACCESS TO THE PUBLI ' f' <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY <br />The Board of Public Works must have four (4) weeks prior notice of the event.. 186, k <br />A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED <br />CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE <br />INCLUDED WITH APPLICATION. <br />Applicant Name: Tina Patton, Pastor <br />Address: 707 Sherman City: SOUTH State: IN Zip <br />Avenue BEND <br />Phone: 574-298-3402 <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the <br />specified public right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name Kingdom Life Christian Cathedral Annual Church Picnic <br />Street Closure Name of Street <br />From <br />To <br />Date of Event August 13 <br />Time Setup 9am <br />Sherman•H-atdre <br />loam �pu\ `�'" <br />3pm V ac &'( e(,\ <br />20 16 <br />N Start 10 <br />a.m. <br />p.m. <br />Approximate Number of <br />Attendees <br />Please answer the following appropriately: <br />Na.m. <br />❑P.m. <br />100 <br />• This event will be open to residents outside the immediate <br />neighborhood. <br />• All residents on the affected block have been notified and invited. A <br />copy of the flyer distributed is included. <br />• This event will have music (live or other). <br />• Payment of $50.00 fee payable to City of South Bend included or: <br />End 3 ❑a.m. Np.m. <br />® Yes ❑ No <br />• For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal <br />Revenue Exemption Status Document and a current copy of Form 990 of <br />Form 990-EZ are included with this application, and additionally filed with <br />the Office of the City Clerk, 4`s Floor, County -City Building, 227 W. <br />Jefferson Blvd., South Bend, Indiana. <br />® Yes ❑ No <br />® <br />Yes <br />❑ <br />No <br />® <br />Yes <br />❑ <br />No <br />❑ <br />Yes <br />❑ <br />No <br />IF ALCOHOL IS TO BE SERVED OR SOLD <br />Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ <br />Certified Check or Money Order for $400.00 must be submitted with application. <br />• Application cannot be processed without deposit. <br />• Deposit will be returned upon inspection of event area by the Board of Public Works. <br />❑■ <br />Updated 4/2013 <br />