Non Res Block Party - Megan Kirwan and Matthew Teters

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APPLICATION FOR USE OF AND BLOCKING OF ACCESS TO, THE PUBLIC a - The Board of Public Works must have FOUR td,)-weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE2'5.00 THE FORM OF A CERTIFIED 61 1" CHECK OR MONEY ORDER PAYABLE TO T4 �TY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. EJ'Fee Paide-i'* Applicant Name: w T-0ors Address: . " "Vlcity: State: Zip: Phone: �5 L4 Email: � _3 a U This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name ,fiver h I Location Street Closure Name of Street From aile, ;r? &mt o i- River (zc, Iz)wn 7o,7uj (Describe Area/Routc)1-hC CMPct-;iLm 16f, t n '-s h),( To C' e��20 Date of Event - j1jj?,e_ �,?h4 20 a ffa.rn. Ram. El am. Time: Registration/Setup 0I P.M. Start p.m. End �rJnl Approximate Number of Attendees Answer the following appropriately: I . This event will have music (live or other). Yes a. I understand the Noise Ordinance described in the Agreement/Perinit Yes 2. Required Information to Accompany Application a. Certified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copics, of the 501 (c)(3) Internal Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are included with this application, and Yes additionally filed with the Office of the City Clerk, 4" Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana. c. Certificate of Insurance 3 d. Maps, drawings and setup plan of the area e. A copy of a flyer or door hanger that has been distributed to all affected property owners. a. This event involves City streets b. This event involves County roads c. This event involves State highways Updated,8/2017 N 10-1 X No No No Yes No Yes No E`- Yes El No El Yes 0 No Yes J9 No I