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APPLICATION FOR SIDEWALK CAFt PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />DATE <br />FEE PAID <br />Applicant's Legal Name 111 L,A-(�_-, Title <br />Business Name <br />Address C ....... . ..... . laa tLY <br />Telephone Number, z t,L—z —"5� 2.. no <br />Proposed Location and Description of Sidewalk Cat'& <br />Days of Sidewalk Caf6 Operation Sun Moil Tries Wed -1,11111-s Fri Sat <br />Hours of Sidewalk Caf6 Operation <br />The following information is REQUIRED for cornpletion of Sidewalk Cafe Application: <br />L Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidcwall: cal,6 Showing placement/dimensions of proposed <br />caf6 <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($ 1,000,000/occurance and $300,000/person, naming the City ot'Soulh Belid <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 iS-,LJancc of this I'Crillit. I 1,01-1her 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 Im a <br />sidewalk caf6 as permitted herein. I do hereby ccrtify and.affirto that all the information given in this applicikon is <br />true to the best of my knowledge, <br />tj Z <br />Date Signature of Al�plicant <br />Prhue(TNanle <br />Ek) ) 0 V <br />Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />President PX&Z e' 1.Mt rttl�ct <br />Member <br />Member <br />RETURN FORM TO� <br />Board, of Publie Works <br />131,6 County -City Building <br />227 West Jefferson Boulevard <br />South l3cnd, IN 46601 <br />Phone: (574) 2359251 a Fax: (574) 23.5-9 t 71 <br />Date <br />