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Application cannot be processed without a copy of this license. <br />12. APPLICANT agrees to indemnify, defend and hold harn-less the Civil City of South Bend, <br />Indiana, fiom any liability, loss, costs, damages or expenses, including attorney fees, which the <br />Civil City of South Bend, may suffer or incur as a result of any claims or actions which may be <br />made by any person, including a participant in the activity, arising out of the approval of this <br />request by the Board of Public Works to close a portion of the public right-of-way for the event <br />described above. <br />I have read the Application and Permit and the Agreement for the CUse of Right -of -Way for Special <br />Events0and I understand and agree to the above rules and regulations. I also understand that this <br />application may be denied based on any false or incomplete information. <br />Dated this '9_7 day of 20 <br />APPLICANT Signature <br />Printed Name <br />BOARD OF PUBLIC WORKS APPROVAL <br />President Member Member <br />Member <br />Phone: (574) 235-9251 <br />Member <br />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 />❑ Fax: (574) 235-9171 ❑ E-Mail: pubhcwks@southbendin.gov <br />