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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:, )49h wp D D. 504 11� D VENU(-6 i�" i &,XS <br />Address; De ~ S. �r 4AUCity: W -?4Wtate: zrU Zip: Yb6 /'7 <br />Phone: ' 5-7aq Email: KMD0 i/1, lb <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 ? �m . SjaeT Fos�41la� . . <br />Location kkt- 141 <br />(Describe Area/Route) <br />Street Closure Name of Street it <br />From S-r. <br />To,,, t <br />Date of Event l ttes. j, 20 <br />.r <br />} ® a.m. 9 a.m. <br />I �'„�` ' <br />❑ a.m. <br />Time: Registration/Setup ❑ p.m. Start ❑ p.m. <br />End , Kp,m. <br />Approximate Number of Attendees [- g D Q ` <br />� <br />_ V <br />Answer the following appropriately: ` ` • <br />`. <br />1. This event will have music Div or other). <br />'Yes ❑ No <br />a. I understand the Noise Ordinance described in the Agreement/Permit:." <br />.® Yes ❑. No, <br />2. Required Information to Accompany Application <br />a. Certified Check or Money Order in the Amount -of $125.00, or: <br />2i <br />b. For Certified Nonprofit Organizations: Copies of°the 501(c)(3) <br />Internal Revenue Exemption Status Docume4bgpd 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, 4ffi Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />c. Certificate of Insurance <br />d. Maps, drawings and setup plan of the area y <br />Yes ❑ No <br />e. A copy of a flyer or door hanger that has been distributed to all <br />® Yes ❑ No <br />affected property owners. <br />3. <br />a. This event involves City streets <br />Yes ❑ No <br />b. This event involves County roads <br />❑ Yes Dj� No <br />c, This event involves State highways <br />❑ Yes. No - <br />Updated 8/2017 <br />I <br />