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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 NUN -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 />F ar <br />ee Paid 45 <br />Applicant Name <br />The LGBTQ Center, Inc., <br />Address: 1522 E Mishawaka Ave— City: South Bend — State: MI Zip: 46615 <br />Phone: 574-234-1411 — Email: _jason(a-_)thelclbtqceriter.ora <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 hereinaft-er described event: <br />Event Name <br />Location South Michigan Ave from Washington Street to Wayne Street including Jeffereson Blvd intersection <br />(Describe Area/Route) <br />Street Closure Name of Street S Michigan St <br />From E Washington Street <br />'ro E avne Street <br />Date of Event Saturday June 16th 20 18 <br />19 a.m. ❑ a.m. a.m. <br />Time: Registration/Setup 10:00 [:] p.m. Start 12:00 p.m, End 6:00 P'm <br />Approximate Number of Attendees 500 <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />FX-1 <br />Yes <br />No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />FX <br />Yes <br />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 />Form 990 of Form 990-EZ are included with this application, and <br />Yes <br />❑ <br />No <br />additionally filed with the Office of the City Clerk, 4 th 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 />Yes <br />Ej <br />No <br />e. A copy of a flyer or door hanger that has been distributed to all <br />Yes <br />No <br />affected property owners. <br />3. <br />a. This event involves City streets <br />Yes <br />❑ <br />No <br />b. This event involves County roads <br />El <br />Yes <br />No <br />c. This event involves State highways <br />F1 <br />Yes <br />M <br />No <br />Updated 8/2017 <br />1 <br />