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Applicant's Legal Name <br />Business Name <br />Address <br />Telephone Number <br />Proposed Location and <br />APPLICATION FOR SIDEWALK CAI t PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />CaI16 <br />I <br />FEE PAID <br />Days of Sidewalk Cafe _0perml_6n_ <br />Hours of Sidewalk CaI16 Operation <br />Sun <br />Moll <br />Tues <br />Wed <br />Thurs <br />Fri <br />Sat <br />Tile following infori-nation is REQUIRED for completion of a Sidewalk Cafd Application: <br />I. Completed/signed application, including a $ 10.00 fee <br />2. Drawing(s) and description of proposed sidewalk caf6 showing placernent/dirriensions of proposed <br />cafd <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, narning 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 frorn 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 caff as permitted herein. I do hereby certify and affirm that all the information given in this application is <br />true tote best of my knowledge. <br />Date rgna reofAphcarit <br />Printed 1,!an-ic <br />al ) <br />Title <br />aRD OF PUBLIC WORKS APPROVAL <br />4�4 <br />President Member Member <br />-7 <br />Member <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 46,601 <br />Pliojie. (574) 235-9251 e Fax: (574) 235-,9171 * E-Mail: publicwks a; <br />