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Application cannot <br />12. APPLICANT agre <br />Indiana, from any 1 <br />Civil City of South <br />made by any perso <br />request by the Boai <br />described above, <br />processed without a copy of this license, <br />to indemnify, defend and hold.harmless the Civil City of South Bend, <br />Aity, loss, costs, damages or expenses, including attorney fees, which the <br />end, may suffer or incur as a result of any claims or actions which may be <br />including a participant in the activity, arising out of the approval of this <br />of Public Works to close a portion of the public right-of-way for the event <br />I have read the Applicati n and Permit and the Agreement for the "Use ofRight-of Way for'Special <br />Events" and I understani I and agree to the above rules and regulations, I also understand that this <br />application may be denie I based on any false or incomplete information. <br />Dated this 2 1 day of '`� 20 d <br />APPLICANT Signature (�( 2�)tJ� _ <br />Printed Name 0J u ail n per- _ <br />BOARD OF PUBLIC WORKS APPROVAL <br />President Me I <br />er Member <br />fd -7Id0 (7 <br />Member Member 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) 235-9 51 • Pax:. (574) 235-9171 * E-Mail: publicwks@southbendin.gov <br />t, ' d OZ T B-68a HPLS I jaujeM uesn5 dLO : Z T L T i s unr <br />