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APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO THE PUBLIC <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES <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 d <br />Applicant Nairte: Fib � /� r/ <br />Address: City: ijsStajte�: p� Zip:" <br />Phone: �•� �� Email:'' 1 G�QvG4 <br />W <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 <br />+by Applicant for the holding of the hereinafter described event: <br />Event Name I 1 r l <br />Location <br />Street Closure <br />Udw "(41- OWMA6 <br />w S i (Describe Area/Route) <br />Name orstreet -�•f <br />From n G a f'lf <br />To <br />Date of Event1...G;_ 20 <br />da.m. <br />Time: Registration/Setup ❑ p,m <br />Approximate Number of Attendees <br />Start El p.m. End �i ❑f <br />C".i p <br />.Answer the following appropriately: <br />1, This event will have music (live or other). <br />Yes ❑ No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />[Vl Yes ❑ No <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 />Forth 990 of Form 990-EZ are included with this application, and <br />❑V Yes ❑ No <br />additionally filed with the Office of the City Clerk, 4th Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />c. Certificate of Insurance <br />` <br />d. Maps, drawings and setup plan of the area <br />d Yes ❑ No <br />e. A copy of a flyer or door hanger that has been distributed to all <br />affected property owners. <br />❑� Yes ❑ No <br />3. <br />a. This event involves City streets <br />Yes No <br />b. This event involves County roads <br />❑ Yes No <br />c. This event involves State highways <br />❑ Yes No <br />Updated 8/2017 <br />1 <br />