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08-23-'16 07:35 FROM- 5742396407 T-550 P0002/0006 F-042 <br />PIERMIT/AGREEMENT <br />1i011 A Pl1Dl'F.SCiQN <br />1• Sponsor shall reimburse the Board for the actual cost to the City for the event, if deemed <br />necessary. <br />Z• Sponsor shall provide to the Board a Certificate of Insurance showing a liability policy in <br />frill force and effect with limits of $300,000.00 per occurrence and $5,000,000.00 <br />aggregate and the City of South Bend listed as an additional named insured for this event, <br />3• Sponsor shall provide to the Board all additional licenses <br />required for the event. , permits and documentation <br />a• Sponsor agrees to abide by all terns and conditions of the Board's policy governing <br />walks, runs, parades or other similar event adopted by the Board on March 3, 1985. <br />5. In order to ensure public safety during the event, the Board agrees to furnish traffic <br />Planning, materials, equipment and personnel as deemed necessary by the Police <br />Department Traffic Bureau, the Bureau of Traffic and Lighting, and, where applicable, <br />the Board of Park Commissioners. <br />6. Sponsor acknowledges that the Police Department reserves the <br />for safety purposes. right to change this route <br />7. In consideration for approval by the Board and the use of the sidewalks for the purposes <br />set out above, the undersigned agrees and undertakes to hold the Civil City of South <br />Bend, Indiana, free and harmless from any liability loss, costs, costs, damages or <br />expenses, including attorney fees, which the Civil City of South Bend may suffer or <br />incur, as a result of any claims or actions which may be made by any person, including a <br />participant in said activity, arising out of the approval of the request to use the sidewalks <br />indicated in the City of South Bend. The undersigned certifies that he/she is authorized to <br />bind the above mentioned sponsor to the terms hereof <br />8. Notification of a_riproval/denial of this request wilt be issued by return of this form, upon <br />signed authorization by the Board of Pablic Works <br />I understand the above rules and regulations and that this application may be denied based on <br />any false or incomplete information. <br />Sponsor Signature <br />Printed Name <br />Title 2 fr ccnn�!_�✓/� " <br />O�CItII OF PUBLIC WORKS APPROVAT <br />A� 4tAJ <br />'resi�9rttt _ Memberf /1. <br />Member <br />q,/13f( <br />Member pate <br />RETURN FORM TO: 2 <br />Board of Public works <br />1316 County -City Building <br />227 West ltffcrsgn Vou!rvard <br />South Bend, IN 46601 <br />Phonon (574) 235-9251 0 Far: (574) 235.9171 9 E-Mail: publicwks@southbendin,gov <br />