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APPLICATION PEACE 4, <br />FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY. q6 1 86 5 <br />The Board of Public Works must have four (4) weeks prior notice of the event. <br />A NON-REFUNDABLE APPLICATION FEE OF $50.00, 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 />Applicant Name: <br />5 51 A" <br />Organization: <br />6 "311 <br />City: <br />State: <br />Address: <br />I'A)644No <br />S-'C"At'6,eNit <br />I <br />Phone: <br />7 ('4jkEmail: w <br />, (I V" -C A - <br />Secondary Contact <br />Address: C� <br />City: State: t I'ce <br />Phone: As A 9, wf Email: 'tl rye <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of <br />the specified ublic right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name <br />(' �_ � ( <br />Name of <br />Street Closure <br />Street <br />From <br />TO <br />No 44 A <br />Date of Event <br />20 <br />Time <br />S <br />( am. Elp.m <br />Start <br />I <br />14a.m. Elp.m. <br />End <br />Elam. <br />p.m, <br />Time <br />Time <br />Approximate Number of <br />SO <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate <br />Yes <br />No <br />neighborhood.__., <br />• All residents on the affected block have been notified and invited. A <br />Yes <br />Ej <br />No <br />copy of the flyer distributed is included. <br />• There is/are resident(s) affected by the event that may need ADA <br />0 <br />Yes <br />No <br />transportation assistance to their residence, <br />-Te—sr: <br />I <br />• This event will have music (live or other). <br />0 <br />—9—yes <br />No <br />• Payment of $50.00 fee payable to City of South Bend included <br />0 <br />No <br />k�" <br />Updated 08/2017 <br />