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APPLICATION <br />FOR USE OF, AND BLOCIONG_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 OI'' $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: Sam Centellas, on behalf of La Casa de Amistad <br />Address: 746 S Meade City: South Bend State: IN Zip: 46619 <br />Office (574) 233-2120 <br />Phone: Cell (616) 610-0042 <br />This applicationn 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 West Side Wednesday Festival Best. Wednesday, Ever. <br />Location 2900 Block of W. Western Avenue <br />(Describe Area/Route) <br />Street Closure Name of street Western Ave (3PM --- IOPM Libel St (6AM — I OP Close on -street parkhig <br />From Kaley Westeni Ave on Western from Bendix <br />To Dundee Jeffersolz to Camden for vendors <br />Date of Event Wednesday, May 30 20 18 <br />❑ kin. ❑ a -ma ❑ a.m. <br />Time: Registration/Setup 1:00 ❑ pan. Start 4.00 ❑ p.m, End 9:00 ❑ p.m. <br />Approximate Number of Attendees 2,000 <br />Answer the following appropriately; <br />1. This event will have music (live or other). <br />x Yes <br />❑ <br />No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />x Yes <br />❑ <br />No <br />2. Required Information to Accompany Application <br />a. Certified Cheek 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 />x Yes <br />❑ <br />No <br />additionally filed with the Office of the City Clerk, 4th 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 />x Yes <br />❑ <br />No <br />3. <br />a. This event involves City streets <br />x Yes <br />❑ <br />No <br />b. This event involves County roads <br />❑ Yes <br />❑ <br />No <br />c. This event involves State highways <br />❑ Yes <br />❑ <br />No <br />d, This event involves the use of the sidewalk <br />x Yes <br />[ <br />No <br />Updated 4/2015 <br />1 <br />