Street Closure - Curtis Leonard Jr.

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APPLICATION X45 RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY The Board of Public Works must have four (4) weeks prior notice of the A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BEI �nG� INCLUDED WITH APPLICATION. e�' "qK-1 Applicant Name:CLki�S L,c.>"Ckr fi S? � Address:iaq br le((� City:S_3-cf\ State:l) Zip(n4L4gZ$ Phone: -1q•SZU•'76qZ(o l'tc,�-cSA t✓e-d riA_r� l lggC , 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 tjkcc_�_ Street Closure Name o Street Ybe--r_1 C) 94-' From Ht kvAbo 4- Date of Event - (—I 20 1(C) Time Setup I Yvt 9- Start C ❑a.m. ® End 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 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) hiternal 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, 41h Floor, County -City Building, 227 W. Jefferson Blvd., South Bend, Indiana. ❑a.m. ®p.m. ® Yes ❑ No 'X❑ Yes ❑ No 19 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. FE Updated 4/2013