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APPLICATION <br />YEAGF. <br />The Board of Public <br />Works must have FOUR (4) weeks prior.notice of the event. <br />A NON-REFUNDABLE <br />APPLICATION FEE OF $125.00, IN THE FORM OF A. CERTIFIED <br />CHECK OR MONE <br />ORDER,. PAYABLE TO THE CITY OF SOUTH BEND, MUST BE <br />INCLUDED WITH APPLICATION. <br />❑ Fee Paid <br />Applicant Name: <br />be n Gk UI C G CND 66 to d a_�I ' <br />Address: a15 5.M <br />vi s-c City: State: Zip: z�i7 <br />Kiv�y ,J42. vZ <br />Phone: <br />This application is made to <br />the City of South Bend, Indiana, Board of Public Works, for the use of the <br />specified public right-of-way <br />by Applicant for the holding of the hereinafter described event: <br />Event Name Gv <br />Ul �JC�-1 " 7�-✓L p� <br />LocationL <br />W\, VJ^P 1:�, <br />_ <br />(Describe Area/Route) <br />Street Closure -Name of <br />Street](/nl-t���� <br />From <br />To <br />C7:2 pm <br />e_r <br />Date of Event C <br />��200 <br />5 a.m. ER/alm.. ❑ a.m <br />Time: Registration/Setup <br />, <br />❑ p.m. Starts ' ❑ p.m, End <br />Approximate Number of <br />kttendees <br />Answer the following appropriately: <br />1. This event will have mu <br />sic (live or other). 50 Yes ❑ No <br />a. I understand the Nc <br />ise Ordinance described in the Agreement/Permit Yes ❑ No <br />2. Required Information to <br />Accompany Application <br />a. Certified Check or <br />Money Order in the Amount of $ I25.00, or: <br />b. For Certified Nonpr <br />ofit Organizations: Copies of the 501(c)(3) <br />Internal Revenue E <br />emption Status Document and a current copy. of <br />Form 990 of Form <br />90-EZ are included with this application, and Yes ❑ No <br />additionally filed wi <br />h the Office of the City Clerk, 4`h Floor, County - <br />City Building, 227 IV. <br />Jefferson Blvd., South Bend, Indiana. <br />c. Certificate of Insur <br />nce <br />d. Maps, drawings of I <br />he area and setup plan [ Yes ❑ No <br />3. <br />a. This event involves <br />City streets Yes ❑ No <br />b. This event involves <br />County roads ❑ Yes 9 No <br />c. This event involves <br />State highways ❑ Yes ® No <br />d. Tills event involves <br />the use of the sidewalk [d Yes ❑ No <br />Updated 4/2015 <br />1 <br />;3'Cl 8ZT8-E8a <br />HVLS] jauuem uesns dLo:aT LT Ta unr <br />