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APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO THE PUBLIC <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES <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 />Applicant Fee Paid <br />INCLUDED WITH APPLICATION. _ `�/ t�, <br />� � <br />Name: Carissa Mencil <br />30 S Meridian St <br />{� <br />Address: Ste 1100 City: Indianapolis State: <br />IN Zip: 46204 <br />Phone: <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 <br />for the holding of the hereinafter described event: <br />Event Name Family Fun Da <br />Location Edd Street Commons 1234 Eddy Street <br />(Describe Area1Ro te) <br />Street Closure Name of Street EddyStreet <br />From An-ela <br />To Napoleon <br />Date of Event 6/I0 20 17 <br />Time: Registration/Setup 8 !� a m. Start 11 a.m <br />L! p ❑ p.m. <br />❑ a.m. <br />End 2 <br />Approximate Number of Attendees <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />Yes ❑ <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />2. Required <br />No <br />Yes ❑ No <br />Information to Accompany Application <br />a. Certified Check or Money Order in the Amount of $125.00, or: <br />b. 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 />14 yes ❑ No <br />additionally filed with the Office of the City Clerk, 4"' Floor, County- <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />c. Certificate of Insurance <br />d. Maps, drawings of the area and setup plan <br />yes ❑ No <br />3. <br />a. This event involves City streets <br />b. This event involves County roads <br />Yes ❑ No <br />❑ Yes <br />No <br />c. This event involves State highways <br />❑ Yes No <br />Updated 4/2015 <br />1 <br />3 <br />