Non Res Block Party - City of South Bend - Dr. King-Fr. Hesburgh Monument Unveiling

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APPLICATION FOR USE OF, AND BLOCKING OF ACCESS TO, THE PUBLIC RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES The Board of Public Works must have FOUR (4) weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. ❑ Fee Paid Applicant Name: Jitin Kain Address: 227 W. Jefferson Blvd City: South Bend State: IN 46601 Phone: 5742355835 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 Dr. King & Fr. Hesburgh Monument Unveiling Location Leighton Plaza, downtown South Bend (Describe Area/Route) Street Closure Name of Street Main Street From Washington St. To Jefferson Blvd. Date of Event June 21 20 17 ® a.m. ® a.m. ❑ a.m. Time: Registration/Setup 10:30 ❑ p,m. Start 11:00 ❑ p.m. End 12:00 ® P.M. Approximate Number of Attendees 200 Answer the following appropriately: 1. This event will have music (live or other). ® Yes ❑ No a. I understand the Noise Ordinance described in the Agreement/Permit ® Yes ❑ No 2. Required Information to Accompany Application a. Certified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are included with. this application, and ® Yes ❑ No additionally filed with the Office of the City Cleric, 4"' Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana. c. Certificate of Insurance d. Maps, drawings of the area and setup plan ® Yes ❑ No 3. a. This event involves City streets ® Yes ❑ No b. This event involves County roads ❑ Yes ® No c. This event involves State highways ® Yes ❑ No Updated 4/2015 1