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Applicant's Legal Nanic 4f'ry h ohrfs Title <br />Business Name <br />Address <br />Telephone Number <br />4-z&U- R�6!2 <br />Proposed Location and Description of Sidewalk C-66 <br />Days of SidowalffCW Operation <br />Hours of Sidewalk CafO Operation <br />Sun Mon I 'Nos Wed "Thugs Fri Sat <br />2-/z 212--12Z 'Z-/�-121 Z-1 � <br />The following information is REQUIRED for completion of a Sidewalk Cafd Application: <br />1. Completed/signed application, including a $10,00 fee <br />2. Drawing(s) and description of proposed sidewalk cafd showing placenicnt/diniensions of proposed <br />C06 <br />3, Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/persoji, naming the City of South Bend <br />as additional insured) <br />AFFIRMATION <br />1, the undersigned, agree that I will abide by all of the provisions of Section 18-15 of the South Bend Municipal <br />Code and with all the provisions stated above as conditions of the issuance of this Permit. I further agree to <br />hidermft defend and hold harmless the City of South Bend fi-om any liability, loss, cost, damage or expenses, <br />including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a <br />sidowalk, caM as permitted herein. I do hereby certify and affirm that all the information given hi this application is <br />true to the best of my knowledge, <br />Date ?-'—'-Signato6of Ap ljoant <br />Je, r r7awm <br />Printed Nan <br />Title <br />Pies"—ident 0MeiqiibeLr L11jL <br />Member Member <br />RE TURN FORM TO: <br />Board of Public Works <br />1316 COLRAY-City Bultding <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 6 Fax: (574) 235-9171 <br />M#ber <br />Date <br />4 <br />