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4, <br />Al <br />APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY <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 />Rami(-x- 1+xde.�t <br />Organization: <br />1-::`,56_tLqS P646orkook <br />Address: <br />Ott K <br />ja.3 <br />City: <br />State: <br />Zip <br />Phone: <br />.5114 — Ll '3,—e) 2"3 5 Email: val'ak.'asia. o�y <br />Secondar Contacl, <br />'54,4 <br />e, n e 5 <br />Address: <br />0- <br />city: ra State: -)'Z-AJ 466,17 <br />Phone: ail: r S(W_AA1 f-W4 <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of' <br />the specified ublic riRht-of-w4y by Applicant for the holding of the hereinafter described event: <br />Event Name <br />tf. A " n L4-6 ( '1v4(q-qdg& C-stLte_�, <br />4�r6�N6o— koqt� Cde_ Cy--eo_vn 5oc_,ja( <br />Name of <br />Street Closure <br />street <br />3�a_en< Oat < Dvioe, <br />From <br />O&Y, <br />To <br />5w+swoocL t>-i\ie <br />Date of Event <br />m4n"I'"e,7-t5 <br />201 <br />1-9 W &j4g_o4 -7' a. 01 <br />Z&, 4vwA, JZA <br />Time <br />Setup <br />0a.m. E&.m. <br />Start <br />Ela.m. Sp.m. <br />End <br />Flam, R <br />Time <br />60030 <br />1 <br />1 Time <br />P-m, <br />Approximate Number of <br />4� <br />Attendees <br />Please answer the following appropriately: <br />9 This event will be open to residents outside the immediate <br />El <br />Yes <br />X <br />No <br />neighborhood. <br />e All residents on the affected block have been notified and invited. A <br />Yes <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 />Yes <br />No <br />transportation assistance to their residence. <br />* This event will have music (live or other). <br />El <br />Yes <br />No <br />0 Payment of $50.00 fee payable to City of South Bend included <br />Yes <br />Ej <br />No <br />M1 <br />Updated 08/2017 <br />