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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 />C11ECK OR MONEY ORDER, PAYABLE TO THE CITY OIL SOUTH BEND, MUST BE <br />INCLUDED WITH APPLICATION. <br />❑ Fee Paid <br />Applicant Name: Elizabeth Leachnian / South Bend Venues Parks & Arts <br />Address: 301 S. St. Louis Blvd, <br />City: South Bend[ State: IN Zip: 46544 <br />Phone: 574-235-5904 <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 Bike & Hike <br />Location Rum ViI1a e Pailc, including mountain bike trails &Gertrude St. <br />(Desoa•ibe Area/Route) <br />Street Closure Name of Sheet Gertrude 5t <br />From Ewing Ave. <br />To Chippewa Ave. <br />Date of Event February 17 20 18 <br />El a,m. El a.in, ❑ a.m. <br />Time: Registration/Setup 8:00 ❑ p.in. Start 11:00 ❑ p.,n. End 4.00 ❑ p.m. <br />Approximate Number of Attendees 500 <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />❑ <br />Yes <br />❑ <br />No <br />a. <br />I understand the Noise Ordinance described in the Agreement/Permit <br />❑ <br />Yes <br />❑ <br />No <br />2. Required Information to Accompany Application <br />a. <br />Certified Check or Money Order in the Amount of $125.00, or- <br />b, <br />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 />❑ <br />Yes <br />❑ <br />No <br />additionally filed with the Office of the City Cleric, 4"' Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />c. <br />Certificate of Insurance <br />d. <br />Maps, drawings of the area and setup plan <br />❑ <br />Yes <br />❑ <br />No <br />3. <br />a. <br />This event involves City streets <br />❑ <br />Yes <br />❑ <br />No <br />b. <br />This event involves County roads <br />❑ <br />Yes <br />❑ <br />No <br />c. <br />This event involves State highways <br />❑ <br />Yes <br />❑ <br />No <br />d. <br />This event involves the use of the sidewalk <br />❑ <br />Yes <br />❑ <br />No <br />Updated 4/2015 1 <br />