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DATE <br />Applicant's Legal Dame <br />Business Name <br />Address <br />Telephone Number <br />APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />FEE PA <br />Title 'v, �T{ pb`� <br />woo C 1 i too ��' <br />Proposed Location and Description of Sidewalk Cafe <br />j3' <br />Days of Sidewalk Cafe Operation <br />Hours of Sidewalk Cafe Operation <br />Sun <br />Mon <br />Tues <br />Wed <br />Thurs <br />Fri <br />Sat <br />I <br />Z <br />I��at <br />I�M7 <br />G <br />Ilfl�►7 <br />�G.0 <br />11 MI <br />2-tv <br />The following information is REQUIRED for completion of a Sidewalk Cafe Application: <br />1, Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafe showing placement/dimensions of proposed <br />cafe <br />3. 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 fi•orn 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 cafe 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. / <br />WLu 2018 <br />Date <br />Signature of Applicant <br />Printed Nan <br />Title <br />BOARD OF PUBLIC WORK APPROVAL i <br />if <br />A"�G�A� <br />President Member Member <br />Member Member Date <br />RETURN FORM TO: 4 <br />Board of Public Works <br />t316 County -City Building <br />227 West Jefferson Boulevard <br />South Send, IN 46601 <br />Plione: (574) 235-9251 • Fax: (574) 235-9171 <br />