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APPLICATION <br />rgja, L S ] I jS& = �tk V _TVF P <br />The Board of Public Works 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, MUST BE <br />INCLUDED WITH APPLICATION. <br />[] Fee Paid <br />Applicant Name: <br />Kara Wood <br />Address: 301 S St Louis Blvd <br />City: South Bend State: IN Zip: 46617 <br />Phone: 574-235-5799 Email: kwood@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 18th Annual Kids Triathlon <br />Location Potawatomi Park & Pool <br />(Describe Area/Route) <br />Street Closure Name of Street Wall St Greenlawn Southwood Ave <br />From Greenlawn Wall St Belmont/Twyckenham <br />TO Ironwood Belmont Ave Greenlawn <br />Date of Event July 14 ------ 20 18 <br />X am. <br />Time: Registration/Setup 5:30 p.m. Start <br />Approximate Number of Attendees <br />W� a.m. W a.m. <br />8:00 F-I p.m. End 11:00 El P.m. <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, 4 1h 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 />c. 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 8/2017 <br />Yes No <br />Yes No <br />Yes No <br />Yes <br />No <br />Yes <br />No <br />Yes <br />R <br />No <br />E I <br />Yes <br />It <br />No <br />Yes <br />No <br />I <br />