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APPLICATION FOR SIDEWALK CAFE PERMIT ` <br />DTE A / c CITY OF SOUTH BEND, INDIANA 63 - <br />�ry - �j FEE PAID $ <br />Applicant's Legal Name 15:f2�Cf Title <br />Business Name <br />Address <br />ST. <br />Telephone Number �j <br />j" <br />Proposed Location and Description of Sidewalk Caf6 <br />414ee 1 <br />Days of Sidewalk Cafe Operation <br />Hours of Sidewalk Cafe Operation <br />Sun <br />Mon <br />Tues <br />Wed <br />Thurs <br />Fri <br />Sat <br />! f-l1i <br />5 <br />The following information is REQUIRED for completion of a Sidewalk Caf6 Application: <br />1. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafe showing placement/dimensions of proposed <br />caf6 <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,0001occurance and $300,000/person, naming the City of South Bend <br />as additional insured) <br />AFFIRMATION <br />I, the undersigned, agree that I will abide by all of the provisions of Section 18-I5 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 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 publ' Iks for a <br />sidewalk caf6 as permitted herein. I do hereby certify and aftirm that all the information en in this a cation is <br />true to the best of my knowledge. <br />Date Signa Applicant 14 <br />A L <br />Printed Name <br />Title <br />OARD OF PUBLIC WORKS APPROVAL <br />Presidenty M ber Member <br />Member Member <br />Date <br />RETURN FORM TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, 1N 46601 <br />Phone: (574) 235-9251 • Fax: (574) 235-9171 9 E-Mail: publicwks@southbendin.gov <br />