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APPLICATION <br />FOR USE OF, AND BLOCKING OF ACCESS TO, THETUBLIC <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES <br />The Board of Public Works must have FOUR (4) weeks prior notice of the event. <br />A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED <br />CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE <br />INCLUDED WITH APPLICATION, Fee Paid <br />Applicant Name: TM VIA ki t �d <br />Address: •City] NState. Zip: Lo <br />evidlan 0 O <br />Phone: Ernail-. <br />This application is rnade to the City of South Bend, Indiana, Board of Public Works, for the use of the <br />specified public right-of-wayfby Applicant for the holding of tile hereinafter described event: <br />(Ur, <br />4- <br />Event Name V 5 0�+e e, <br />Location <br />Street Closure Name of Sti-ect <br />From _rH 1 VIVIV, <br />1) <br />A To "WVy_L <br />Date of Event J(A19 I_t' - 20 <br />V ti. in <br />Time: Registration/Setup El pli <br />Approximate Number of Attendees <br />(Describe Area/Route) <br />V, . M. <br />Start El P-111, <br />End heE] ni. <br />p'.In. <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />n/ Yes E] No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />Yes E] No <br />2. Required Information to Accompany Application <br />a, Certified Check or Money Order in the Amount of $125,00, or: <br />b. For Certified Nonprofit Organizations: Copies of the 5 0 1 (c)(3) <br />Internal Revenue Exemption Status Document and a current copy of <br />Form 990 of Form 990-EL are included with this application, and <br />R/ Yes El No <br />additionally filed with the Office of the City Clerk, 4"' Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend , Indiana. <br />c. Certificate of Insurance <br />d. Maps, drawings and setup plan of the area <br />V( Yes F] No <br />e. A copy of a flyer or door hanger that has been distributed to all <br />Yes No <br />affected property owners. <br />3. <br />a,. This event involves City streets <br />Yes [] No <br />ji <br />b. This event involves County roads <br />El Yes No <br />c. This event involves State highways <br />[:] Yes No <br />Updated 8/2017 <br />