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APPLICATION F^�� <br />r z z <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 />Organization: <br />Address: <br />tie 2 <br />I•,Mr�rirS <br />City: <br />�1�- <br />State* <br />ZL'I1 <br />Phone: <br />� � � Email: <br />Secondary Contact <br />Address: <br />City: State: <br />Phone: .� ! 2 4Z Email: I <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for Me -use of <br />the specified ubl' right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name <br />Name of <br />Street <br />Street Closure <br />From <br />To <br />[� (A' It t,,d <br />Date of Event <br />yl { <br />2 <br />Time <br />Setup <br />a.m. ❑p.m. <br />Start <br />ga.m. ❑p.m. <br />End <br />❑a.m. <br />-.i <br />/ <br />Time <br />/I>; c,(,o <br />Time <br />' <br />p.m. <br />Approximate Number of <br />�`-- <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate <br />❑ <br />Yes <br />No <br />neighborhood. <br />• All residents on the affected block have been notified and invited. A <br />Yes <br />❑ <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 />❑ <br />Yes <br />No <br />transportation assistance to their residence. <br />• This event will have music (live or other). <br />❑ <br />Yes <br />® <br />No <br />• Payment of $50.00 fee payable to City of South Bend included <br />❑ <br />Yes <br />;Xq <br />No <br />Updated 08/2017 <br />