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APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SCATti BE, ND, INDIANA <br />DATE <br />Applicant's Legal Name ,rCC,�r �✓ ,/ "Title <br />Business blame ,✓` 1 _ / k. — <br />FEE P. <br />Address <br />Telephone Number <br />Proposed Location and Description of Sidewalk Cafe <br />Days of Sidewalk Cafe Operation <br />flours of ,Sidewalk Cafe Operation <br />Sun <br />Mon <br />Tues <br />Wed. <br />Thurs <br />Fri <br />Sat <br />" <br />i`% <br />1 <br />c1.._ <br />// <br />4 <br />The following information is REQUIRED for completion of 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 />cafe <br />3. Completed/signed. Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/pers0n, 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 harmless 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 />3 /,_;� 7/,A) <br />Da ature of Applicant <br />e' <br />Printed Name <br />tl" <br />T Titl <br />BOARD OF PU IC WORKS APPROVAL <br />" <br />President Member Member <br />Member Member ]date <br />RETURN FORM TO: 4 <br />Board of Public Works <br />1.31.6 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, fN 46601 <br />Phone. (574) 235-9251 e Fax: (574) 235-9171 9 E-Mail: pLiblicwks(rr)southbendiii.gov <br />