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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 />INCLUDED WITH APPLICATION. <br />❑ Fee Paid <br />Applicant Name: JONATHAN JONES <br />Address: 2203 BASIN ST. City: South Bend State: IN Zip: 46614 <br />Phone: (574) 707-5345 <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 for the holding of the hereinafter described event: <br />Event Name 2017 Urban Adventure Games <br />Location Four Winds Field (501 W. South St., South Bend, IN 46601 <br />(Describe Area/Route) <br />Street Closure Name of Street South St. <br />From Taylor St. <br />To Lafayette Blvd. plus a temporary blocking of intersection w/ South St. for 15 min. <br />Date of Event 7-29 20 17 <br />N a.m. N a.m. <br />❑ a'M <br />Time: Registration/Setup 5:00 ❑ p.m. Start 7:50 ❑ p.m. <br />End 1:00 ® p.m. <br />Approximate Number of Attendees 800 <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />N Yes ❑ No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />N Yes ❑ No ' <br />2, Required 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 />® 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 />® Yes ❑ No <br />b. This event involves County roads <br />❑ Yes ® No <br />c. This event involves State highways <br />❑ Yes N No <br />d. This event involves the use of the sidewalk <br />® Yes ❑ No <br />Updated 4/2015 <br />1 <br />