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APPLICATION FOR SIDEWALK CAFt PERMIT <br />CITY OF SOUTu BEND, INDIANA <br />Applicant's Legal Name ft W f 9. Y) Title <br />Business Name 1,0 "6 ?, � 4 (4,*% <br />') <br />A 'I <br />Address <br />Telephone Number <br />Proposed Location and Description of Sidewalk Caf6 <br />I A " <br />Days, of Sidewalk Caf6 Operation Sun I Mon Tries I Wed I Thurs I Fri Sat <br />Hours of Sidewalk Cafd Operation <br />The following information is RE, QUIRED foi- completion of a Sidewalk Cafd Application: <br />1. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafd showing placement/dimensions of proposed <br />caf6 <br />1 Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend <br />as additional insured) <br />AFFIRMATION <br />1, the undersigned, agree that I will abide by all of the provisions of Section 18-15 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 public sidewalks for a <br />sidewalk calid as permitted herein. I do hereby certify and affirm that all the information given in this application is <br />true to the best of my knowledge. --I <br />6/wl <br />Date Signature of Applicant <br />Printed Name <br />nam*.Wl <br />Title - <br />BOARD OF PUBLIC WORKS APPROVAL <br />President Member Member <br />401 <br />'ember <br />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, IN 46601 <br />Phone: (574) 235-9251 @ Fax: (574) 235-9171 9 E-Mail: pobliewks 0a soutlibendin.gov <br />11 <br />IN <br />