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O`'0V fH & <br />hQ <br />APPLICATION <br />FOR USE OF, AND BLOCKING OF ACCESS TO, THE PUBLIC ri <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES e <br />1965 <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: St. Joseph Catholic Church <br />Address: 711 East Colfax City: South Bend State: IN Zip: 46617 <br />Phone: 574-234-3134 <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 Saint Nick 6k <br />Location <br />Street Closure <br />Date of Event <br />East Race and East Bank Trail (see attached ma <br />Name of Street <br />From <br />To <br />December 10 <br />(Describe Area/Route) <br />Hill nbaler, MIS. and, 'M112MOTI,.r__,. •r •i <br />a(� <br />20 16 <br />X a.m. X a.m. X a.m. <br />Time: Registration/Setup 7:00 ❑ p.m. Start 10:00 ❑ p.m. End 11:45 ❑ p.m. <br />Approximate Number of Attendees 460 <br />Answer the following appropriately: <br />1. This event will have music (live or other). Yes ❑ No <br />a. I understand the Noise Ordinance described in the Agreement/Permit Yes ❑ No <br />2. Required Information to Accompany Application <br />a. <br />Certified Check or Money Order in the Amount of $125.00, or: <br />b. <br />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 />❑ <br />No <br />additionally filed with the Office of the City Clerk, 4'h Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />c. <br />Certificate of Insurance <br />d. <br />Maps, drawings of the area and setup plan <br />10 <br />Yes <br />❑ <br />No <br />3. <br />a. <br />This event involves City streets <br />f9 <br />Yes <br />❑ <br />No <br />b. <br />This event involves County roads <br />❑ <br />Yes <br />[9 <br />No <br />c. <br />This event involves State highways <br />❑ <br />Yes <br />No <br />d. <br />This event involves the use of the sidewalk <br />Yes <br />❑ <br />No <br />Updated 4/2015 <br />1 <br />