Non Res Block Party - St Joseph Grade School

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APPLICATION FOR USE OF AND BLOCKING OF ACCESS TO THE PUBLIC RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES The Board of Public Works must have FOUR (4) weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. Paid � ; Applicant Name: J 0 ePk (lid-luI ,L, -0b Address:�� ',i t ( �4� • City:. State: Zip: �((Q Phone: Email: I' VQ n 6 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 Location (Describe Area/Route) Street Closure Name of Street From To Date of Event ( (p 20 ❑ a.m. ED a.m. ❑ a.m. Time: Registration/Setup ❑ p.m. Start ) ❑ p.m. End I,, q j R P.M. Approximate Number of Attendees_ Answer the following appropriately: 1. This event will have music (live or other). a. I understand the Noise Ordinance described in the Agreement/Permit 2. Required Information to Accompany Application a. Certified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies 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 additionally filed with the Office of the City Clerk, 4'h Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana. c. Certificate of Insurance 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. 3. Yes ❑ No Yes ❑ No Yes ❑ No r Yes E No ❑ Yes ❑ No a. This event involves City streets 0 Yes ❑ b. This event involves County roads ❑ Yes [1 c. This event involves State highways ❑ Yes ✓Q' Updated 8/2017 No No No 1