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Tobacco Commission at (317) 234-4315 for more information. Application cannot be <br />processed without a copy of this license. <br />12. APPLICANT agrees to indemnify, defend and hold harmless the Civil City of South Bend, <br />Indiana, from any liability, loss, costs, damages or expenses, including attorney fees, which <br />the Civil City of South Bend, may suffer or incur as a result of any claims or actions which <br />may be made by any person, including a participant in the activity, arising out of the approval <br />of this request by the Board of Public Works to close a portion of the public right-of-way for <br />the event described above. <br />I have read the Application and Permit and the Agreement for the "Use of Right -of -Way for <br />Special Events" and I understand and agree to the above rules and regulations. I also understand <br />that this application may be denied based on any false or incomplete information. <br />Dated this qtk day of <br />APPLICANT Signature <br />20 4 io <br />Printed Name M )Ck4- it Z CZerQ d � wno-- o <br />e-cAF- woad. f F;, Ra-6e.r. r4 Fef,� <br />BOARD OF PUBLIC WORKS APPROVAL <br />Presicjpnt ,�I I�1 I ember Member <br />Member Member Date <br />RETURN FORM TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 • Fax: (574) 235-9171 9 E-Mail: publicwks@southbendin.gov <br />