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Applicant's Legal Name G1��{� �1 CJ�O�� Title <br />Business Name <br />Address <br />Telephone Number <br />Proposed Location and Description of Sidewalk Cafd <br />Days of Sidewalk Cafe Operation <br />Hours of Sidewalk Cafe Operation <br />Sun <br />Mon <br />Tues <br />Wed <br />Thurs <br />Fri <br />Sat <br />11- i <br />` <br />ll -- I\ <br />1 k- �I <br />t <br />(Iv,�- Q y"` <br />The following information is REQUIRED for completion of a Sidewalk Cafe Application: <br />I. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafe showing placement/dimensions of proposed <br />cafd <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend <br />as additional insured) <br />AFFIRMATION <br />1, the undersigned, agree that I will abide by all of the provisions of Section 18-15 of the South Bend Municipal <br />Code and with all the provisions stated above as conditions of the issuance of this Permit. I further agree to <br />indemnify, defend and hold han-iless the City of South Bend from any liability, loss, cost, damage or expenses, <br />including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a <br />sidewalk cafe as permitted herein. I do hereby certify and affirm that all the information given in this application is <br />true to the best of my knowledge. <br />t2,� l� <br />Date T� s Signature of A`ppliicaant <br />?--, , ,4 <br />Printed Name <br />Title <br />..,7,,,,BOARD OF PUBLIC WORKS APPROVAL <br />_Q uk <br />President Member etn ei <br />emberNVinber Date j <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) 235-9251 . F= (574) 235-9171 <br />4 <br />