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APPLICATION <br />F <br />The Board of Public Works must have four (4) weeks prior notice of the event, <br />PPACN.. , <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 />qmlurc <br />City <br />Sta �: j <br />N <br />`- NOX <br />Address: <br />Phone: <br />�j:qr <br />r^ <br />s Z / � ' b ail: ynS Y16�/'�� I <br />Secondary Contact 3V14(onda ,j�l-1 /j j� U'p ,' <br />Address <br />Ken moI <br />City: D q Th State: _JhJ <br />Phone: - Email: ................. <br />This application is made to the City df South Bend, Indiana, Board of Public Works, for the use of <br />the specified public right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name <br />Name of <br />Street <br />j oj <br />Street Closure <br />From <br />To <br />Date of Event <br />20 <br />Time <br />Setup <br />10 <br />a.m. p.m. <br />Start <br />10�'� <br />❑a.m. ❑p•m• <br />End <br />❑a.m. <br />p.m. <br />Time <br />Time <br />Approximate Number of <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate <br />Yes <br />❑ <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 />Yes <br />❑ <br />No <br />• Payment of $50.00 fee payable to City of South Bend included <br />Yes <br />❑ No <br />9 <br />Updated 08/2017 <br />