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o4SoU TH N" <br />4 O <br />APPLICATION � <br />FOR THE USE OF, AND BLOCKING OF ACCESS TO THE PUBLI(� <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY <br />1865 <br />The Board of Public Works must have four (4) weeks prior notice of the event. l <br />A NON-REFUNDABLE APPLICATION FEE OF $50.00, 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 />Applicant <br />Name: Y,i^i�/, <br />Address: f' of c.t� y 1 Ar. City: �' rwx ,, State: d�Ccyjw Zip '4(w7 <br />Phone: 5n4 -ate-99o2 <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-J(eGI- Pax+y <br />Street Closure Name of Stref L&-Sct l I e A <br />From 1 L0 y Cr.Rv i h&-m <br />To �S'1h2f� <br />Date of Event 01 /1 c f 20 40 <br />Time Setup ❑ Start ❑a.m. End <br />❑a.m. 17p.m. <br />a.m. F3]p.m. <br />m <br />p.m. <br />Approximate Number of <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate <br />❑ Yes 2" No <br />neighborhood. <br />• All residents on the affected block have been notified and invited. <br />Yes ❑ No <br />A copy of the flyer distributed is included. <br />• This event will have music (live or other). <br />❑ Yes 2� No <br />• Payment of $50.00 fee payable to City of South Bend included or: <br />Rr Yes ❑ No <br />• For Certified Nonprofit Organizations: Copies of the 501(c)(3) <br />❑ Yes [Z No <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 />additionally filed with the Office of the City Clerk, 4ch Floor, <br />County -City Building, 227 W. Jefferson Blvd., South Bend , <br />Indiana. <br />IF ALCOHOL IS TO BE SERVED OR SOLD <br />Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ <br />Certified Check or Money Order for $400.00 must be submitted with application. ❑ <br />• Application cannot be processed without deposit. <br />• Deposit will be returned upon inspection of event area by the Board of Public Works. <br />Names and phone numbers of THREE security guards ❑ <br />Updated 4/2013 <br />