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DATE <br />Applicant's Legal Narne <br />Business Name <br />Address <br />Telephone Number <br />APPLICATION FOR SIDE, WALK CAI t PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />J�reMA iwm Title I <br />Proposed Location and Description of Sidewalk Caf6 <br />FEE PjB,$ <br />. ..... . ... <br />Days of Sidewalk Caf6 Operation <br />Sun <br />Mon <br />Tues <br />Wed <br />Thurs <br />Fri <br />Sat <br />k rilw <br />YI-PM <br />-- <br />I 1PK <br />:FftDm <br />(9.prn <br />Hours of Sidewalk Cafe Operation <br />ytm <br />l� _ <br />�t <br />'the foltowing information is REQUIRED for completion of a Sidewalk Caf6 Application: <br />I. Cornpleted/signed application, including a S 10.00 fee <br />2. Drawing(s) and description of proposed sidewalk caf& showing placeirienl/dimensions of proposed <br />cafe <br />3. Completed/signed Agreement <br />4, Certificate Of Insurance ($1,000,000/occurance and $300,(i00/person, 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 fi-orri miy liability, loss, cost, damage or expenses, <br />including attorney fees, which the City may stiffer or incqj:-as the result of any use of the public sidewalks for a <br />sidewalk cafe as permitted herein. I do hereby certify <br />rn t all the information given in this application is <br />true to the best of my knowledge. <br />go <br />Date <br />Signature of Applicant <br />-Je4w Y,7v* -- <br />Printed Natut U <br />Title <br />BOARD RD F PUBLIC WORKS APPROVAL <br />President <br />Member <br />Member <br />Member Member <br />RETURN FORMTO: <br />Board of Public Works <br />1316 County-Cily Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 a Fax: (574) 235-917 1 <br />Date" <br />11 <br />