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APPLICATION vd� \J FOR THE USE OF AND BLOCKING OF ACCESS TO THE PUBL RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY �' 'p F: The Board of Public Works must have four (4) weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. Applicant Name: Ko Address: L4O2 Ih S . City: SpU) (mod State:T- y0� Zip _p17 Phone: 6'7 y-- 532 ` ]C13 This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name krq'S I.' N�UH-6CP Iwb bWLKPAKV Street Closure Name of L— ++e - Street From Mhl�t)N Si: To eL-�M ST Date of Event t LP--j (- 1'7 20 Time Setup,3pm ❑ start y ❑a.m. d End ❑a.m. 0'p.m. 2 p.m. Approximate Number of Attendees Please answer the following appropriately: • This event will be open to residents outside the immediate Ef Yes ❑ No neighborhood. • All residents on the affected block have been notified and invited. A ❑'� Yes ❑ No copy of the flyer distributed is included. • This event will have music (live or other). Ell Yes ❑ No • Payment of $50.00 fee payable to City of South Bend included or: 9 Yes ❑ No • For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal ❑ Yes 9 No Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are included with this application, and additionally filed with the Office of the City Clerk, 4"' Floor, County -City Building, 227 W. Jefferson Blvd., South Bend, Indiana. IF ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ Certified Check or Money Order for $400.00 must be submitted with application. ❑ • Application cannot be processed without deposit. • Deposit will be returned upon inspection of event area by the Board of Public Works. Updated 4/2013 1