Block Party-Residential - Colfax Block Party

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APPLICATION 111L` V ar, yr yr II%- .r as l v I "r, ru13L - �/( RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY The Board of Public Works must have four (4) weeks prior notice of the event. --isbs A ON -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. Applicant Name: Halrun Luppes Address: 1615 E. City: SOUTH State: IN Zip 4 661 Colfax Ave. BEND Phone: 734-480-2219 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 Colfax Block Parry Street Closure Name of Street From To Date of Event September 11 Time Setup 3:00 Colfax Avenue Twyckenham Esther 20 16 ❑ Start 4:00 ❑a.m. a.m. ®p.m. p.m. Approximate Number of Attendees Please answer the following appropriately: • This event will be open to residents outside the immediate End 7:00 ❑a.m. ®p.m. neighborhood. • All residents on the affected block have been notified and invited. A copy of the flyer distributed is included. • This event will have music (live or other). • Payment of $50.00 fee payable to City of South Bend included or: • 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 additionally filed with the Office of the City Clerk, 4a' Floor, County -City Building, 227 W. Jefferson Blvd., South Bend, Indiana. ❑ Yes ® No ® Yes ❑ No ❑ Yes ® No ® Yes ❑ No ❑ Yes ❑ No 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