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APPLICATION <br />FOR USE OF, AND BLOCKINGOF ACCESS TO, THE PUBLIC <br />RIGHT-OF-WAY FOR NON -RE SIDENTIAL 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 />fNCLUDED WITH APPLICATION. <br />F] Fee Paid <br />Applicant Name: ( ,CLIWIV WetLv DoLtrD-Ickld P/0G1eUyA <br />Address: P05 <br />J�,,,Ptljd State: '7,DO Zip. <br />♦ <br />Phone: Email: enA 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: A <br />Event Name <br />F-(r-P-kkxo&f, 4r Mlw+ffig <br />Location (crs Uf-�' flkl pz� 4n'o- <br />Lr- firptoorl <br />(Describe Area/Route) <br />Street Closure Name of Street <br />Froin oi Lep A�, <br />it"41 -, <br />TA <br />o <br />Date of Event 20 <br />[I a,ni. El a.m.. <br />Time: Registration/Setup -7: ap"In' Start 54P'm <br />E+a.rn. <br />End Op.m. <br />Approximate Number of Attendees <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />EQ Yes ❑ No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />Yes F1 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 Organ izations: 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 F-1 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 />Yes E] No <br />e. A copy of a flyer or door hanger that has been distributed to all <br />Yes E] No <br />affected property owners. <br />3. --# <br />a. This event involves City streets Yes F-1 No <br />b. This event involves County roads F-1 Yes No <br />c. This event involves, State highways E] Yes No <br />Updated 8/2017 1 <br />