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APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />DATE <br />FEE PAID <br />Applicant's Legal Name //n Title 'A <br />L�'O170.f� PL'M+ Z'C✓1eV4 munGgeV <br />Business Name / <br />C`�nCo S .1 nfL'vna/^ww <br />Address <br />112 w L'o/FgX ct�a <br />Telephone Number <br />Proposed Location and <br />Days of Sidewalk Cafe Operation <br />Hours of Sidewalk Caf6 Operation <br />Sun <br />Mon <br />Tues <br />Wed <br />Thurs <br />Fri <br />Sat <br />1'y "' <br />i1 y"' <br />y <br />a �- <br />A 4� <br />'1 "' <br />l <br />ji'r` <br />n <br />The following information is REQUIRED for completion of a Sidewalk Caf6 Application: <br />1. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk caf6 showing placement/dimensions of proposed <br />caf6 <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend <br />as additional insured) <br />AFFIRMATION <br />1, the undersigned, agree that I will abide by all of the provisions of Section 18-15 of the South Bend Municipal <br />Code and with all the provisions stated above as conditions of the issuance of this Permit. I further agree to <br />indemnify, defend and hold harmless the City of South Bend from any liability, loss, cost, damage or expenses, <br />including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a <br />sidewalk caf6 as permitted herein. I do hereby certify and affirm that all the information given in this application is <br />true to the best of my knowledge. <br />Date ignature of Appli n <br />�i9h G(%/Cje <br />0 �UYCov� <br />Printed Name <br />1,3zoeva / M ✓ra4n 1/ <br />Title <br />- BOARD OF PU LIC WORKS APPROVAL <br />President Member Member <br />L _y <br />Member <br />-3�/V/-20 r7 <br />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 • E-Mail: publicwks@southbendin.gov <br />