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APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO THE PUBLIC <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. <br />4-4- <br />E] Fee Pai <br />Applicant Name: <br />Address: �1 . �� �� �,C'City: State: Zip: 4 bbo( <br />Phone; �` }- j -` ' Email: _ �ZLC� �Il(�.0 t~r C- f- C>\f- <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the <br />specified public right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name <br />Location <br />(Describe Area/Route) <br />Street Closure Name of Street �t 6rN \' C� t'\ <br />From <br />To <br />Date of Event 20 <br />❑ a.m. ❑ a.m. <br />Time: Registration/Setup Rp.m. Start 10 . P-15-m. <br />❑ a.an. <br />End , C� . ar.m. <br />Approximate Number of Attendees <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />Yes ❑ No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />Yes ❑ 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 501(c)(3) <br />Internal Revenue Exemption Status Document and a current copy of <br />Form 990 of Form 990-EZ are included with this application, and <br />❑ Yes [ No <br />additionally filed with the Office of the City Clerk, 4`t' 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 />Yes ❑ No <br />e. A copy of a flyer or door hanger that has been distributed to all <br />❑ Yes 12- No <br />affected property owners. <br />3. <br />a. This event involves City streets <br />Ef"' Yes ❑ No <br />b. This event involves County roads <br />❑ Yes No <br />c. This event involves State highways <br />❑ Yes No <br />Updated 8/2017 <br />