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DATE 3--z / <br />APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />GC> t5c�iar <br />Telephone Number 5,> 4t ,-23 q—��'1" <br />Proposed Location and Description of Sidewalk Caf6 <br />Days of Sidewalk Caf6 Operation <br />Hours of Sidewalk Caf6 Operation <br />Sun <br />Mon <br />Toes <br />Wed <br />Thurs <br />Fri <br />Sat <br />10 —(c7 <br />t c) /O <br />lo. / o <br />O ` /b <br />o ' /o <br />I t 0 0 <br />10'7 c) <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 cafe 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 />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 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 />-17 <br />Date lSignature of Applicant <br />Printed Name <br />Title <br />r/ J - J 4, <br />President Member <br />Member <br />j o20 / 7 <br />Member Member <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 />11 <br />