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APPLICATION FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY The Board of Public Works must have four (4) weeks prior notice of th A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OI CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. Applicant Name: Organization: Address: 10 �, us�N S,`c City: � C State: �N Zip j4617 Phone: � �t SS _ 0 Email: N "C £ Aa Aqa 6 kpl- _ J{ Secondary Contact Address: A 0e... City: 5/0 .. -01 State: Phone: j (t a ?> Email: ,cow . This application is made to the City of South Bend, Indiana, Board of ublic Works, for the use of the specified pubiic ri ht-of wa by Applicant for the holding of the hereinafter described event: Event Name ;�L ,`�/� �l f�� p�%p �� c 0 Street Closure Name of Street C . W / a 5 ' V510t From :E;�-.1/N S ,' dv— A (At TO2�..� J, Date of Event 20 Time Setup f f : JO I a.m.. C]p.m. Start Time v 0 ❑a.m. L p.m. End Time i� ; �d a.m. p.m. Approximate Number of Attendees " Please answer the following appropriately: • This event will be open to residents outside the immediate neighborhood. ❑ Yes Z No • All residents on the affected block have been notified and invited. A copy of the flyer distributed is included. Yes ❑ No • There is/are resident(s) affected by the event that may need ADA transportation assistance to their residence. ❑ Yes No • This event will have music (live or other). ❑ Yes No • Payment of $50.00 fee payable to City of South Bend included Yes ❑ No Updated 08/2017