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APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />DATE <br />Applicant's Legal Name <br />Business Name <br />Address <br />Telephone Number <br />Proposed Location and Description of Sidewalk Cafd <br />FEE P <br />Days of Sidewalk Cafd Operation <br />Hours of Sidewalk Cafd Operation <br />Sun <br />Mon <br />I Tries <br />I Wed <br />I Thurs <br />Fri <br />at <br />u <br />The following information is REQUIRED for completion of a Sidewalk Cafd Application: <br />1. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafd showing placement/dimensions of proposed <br />cafd <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 />I, 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 cafd 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. �1 <br />Datk / Siet[aiureofAFulidbnt' <br />CTe wl <br />Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />President Member Member <br />0b 7 / I7 <br />Member Member Date <br />RETURN FORM TO: 4 <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 />0 <br />