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APPLICATION <br />FOR USE OF, AND BLOCKING OF ACCESS TO THE PUBLIC <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES <br />The Board of Public Works must have FOUR (4) weeks prior notice of the event. <br />A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED <br />CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE <br />INCLUDED WITH APPLICATION. ` <br />['fee Paid <br />Applicant Name: �- Sat.�Tff R�Nij LLL. <br />Address: Y22 Mis ff,gwh City: State: Zip <br />$ AVC So- n+ 13E-N 9 IN `%6 % (5 <br />Phone: 5-7 y - 3 01- 7 17 ? <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 <br />Location <br />Ar-4 -Fes* <br />Z 3 -A Sfi,.r 19, ft.." /-,u 5 kAkivkkA Arve d- V,^,. Sr . <br />(Describe <br />Street Closure Name of Street Z 3 rA 5+. <br />From MIS 44W4LA AV€ <br />To ALLF—Y 6ezwra.t IUV" Piylc !Mi%d heAAAJ4 a'f/w.i/z.vkj [o't. <br />Date of Event ` } 20 u. ---,� <br />Time: Registration/Setup M. Start tya.m. End Ela.m. <br />g ❑ P.m. to ❑ P.M. E p.m. <br />Approximate Number of Attendees 3 00 <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />ER' Yes <br />❑ No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />Yes <br />❑ No <br />2. Required Information to Accompany Application <br />a. Certified Check or Money Order in the Amount of $125.00, or: <br />[� <br />❑ <br />b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) <br />Internal Revenue Exemption Status Document and a current copy of <br />Form 990 of Form 990-EZ are included with this application, and <br />Yes <br />No <br />additionally filed with the Office of the City Clerk, 41 Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />c. Certificate of Insurance <br />d. Maps, drawings of the area and setup plan <br />❑ Yes <br />❑ No <br />3. <br />a. This event involves City streets <br />Yes <br />❑ No <br />b. This event involves County roads <br />❑ Yes <br />❑ No <br />c. This event involves State highways <br />❑ Yes <br />❑ No <br />d. This event involves the use of the sidewalk <br />❑ <br />❑ <br />Yes <br />No <br />Updated 4/2015 <br />