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APPLICATION FOR SIDENVALKCAFt fttmirr <br />DATE 141r CITY 01; Sourti BEND, INDIANA <br />Applicant's Legal Name <br />Business Name <br />t Ulf <br />Al/ 00 <br />FEE PAID 'E_1_$.JjI <br />Address ........... 1,2 V 1J, MAW -s- - -I -j <br />Telephone Number '51 ;2 '3,2 - 2.- <br />Proposed Location and Description of Sidewalk Caf6 <br />V, P bo (_ <br />Erl <br />Days of Sidewalk Caf6 Operation Sun Mon Ties )\107id ThUrS <br />AM, <br />Hours of Sidewalk Caf6 Operation VPM // Jr''M i I FW <br />, W1 /-)) /� <br />Fri Sat <br />The following information is REQUIRED foi- completion of Sidewalk Caee Application: <br />l. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk care showing placenient/dimensioris ofproposcd <br />caf6 <br />3. Cornpleted/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, narriing the City ot'South Bend <br />as additional insured) <br />AFFIRMATION <br />1, the undersigned, agree that I will abide by all of the provisions of'Scotiori 18-15 Ol'tl]C South Bend NlUrliCipal <br />Code and with all the provisions stated above as conditions Of the issuance of'this Pernik. I ffirther 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 01' ill=, as the result Of any USC of the public sidewalks for a <br />sidewalk caf6 as permitted herein, I do hereby certify and affirin that all the iliffirinalion givcll in this application is <br />true to the best of my knowledge, <br />Date SignU(UrC ofApplicant <br />Printed Name <br />Title <br />BOARD OFPUBLIC WORKS APPIWVAL <br />Prjsjiden�t�' —MAember �embWr <br />Member <br />Member <br />RETURN FORM TO� <br />Board of Ilublic Works <br />1316 County -City Buildint <br />227 WCSt JeffUS011 BOL&V,11-d <br />SOUth Bend, IN 46601 <br />Phone: (574) 235-9251 9 Fax: (574) 235-9 l 71 <br />Da(e <br />4 <br />