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APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO THE PUBLIC <br />RIGHT-OF-WAY FOR NON-RE'SIDENTIAL BLOCK PARTIES <br />The Board of Public 'Forks 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, MIDST BE <br />INCLUDED WITH APPLICATION. <br />[:] Fee Paid <br />Applicant Name: Therese Dorau, City of South, Bend Office of Sustainiability <br />Address: 227 W Jefferson Blvd STE 1316 City: South Bend State: IN Zip: 46601 <br />Phone: 574-235-9323 Email: tdorau@southbendin.gov <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 Mav the 4th Electric Vehicle Ride & Drive Event <br />Location 122 S. Michigan Street, South Bend, IN <br />(Describe Area/Route) <br />Street Closure Name of Street 10 parking spaces only (no street closure), east side of S Michigan Street <br />From South Bend' Chocolate Cafe <br />To ADA Reserved Barking Space (see attached illustrations) <br />Date of Event May 4 20 13 <br />F� a.m. ® a.m. ® a.m. <br />Time. Registration/Setup 4 ® p.rm Start 5 [ p.m. End. S p.m, <br />Approximate Number of Attendees 50 <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />2, Required Information to Accompany Application <br />a. Certified Check 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 />additionally filed with the Office of the City Clerk, 41h 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 <br />e. A copy of a flyer or door hanger that has been distributed to all <br />affected property owners. <br />3. <br />a. This event involves City streets <br />b. This event involves County roads <br />c. This event involves State highways <br />Updated 8/201.7 <br />❑ Yes ® No <br />Q Yes ❑ No <br />n <br />Yes <br />❑ <br />No <br />R <br />Yes <br />❑ <br />No <br />nX <br />Yes <br />No <br />❑ <br />Yes <br />Q <br />No <br />❑ <br />Yes <br />0 <br />No <br />I <br />