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APPLICATION <br />D BLOCKING OF ACCESS TO P B& <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY <br />The Board of Public Works must have four (4) weeps prior notice of the event. <br />A NON-REFUNDABLE APPLICATION FEE OF $ 0..00, IN THE FORM OF A CERTIFIED <br />CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, mUS"I" BE <br />INCLUDED WITH APPLICATION. <br />Applicant Name: <br />Organization: <br />City: <br />S <br />Zip <br />Address : <br />- <br />Phone: <br />Email: <br />Secoadary Contact <br />Address: <br />City State: <br />Phone:" j, ? _Email: <br />This application is made to the City of South Bend, Indiana, Board cif Public Works, for the use of <br />the specified public ri ht-of=vra b A licant for the holdin of the hci'eiixafler described event: <br />Event Name <br />Name of <br />Street Closure <br />Street <br />From <br />TO <br />Dine of Event <br />20. <br />Time <br />Setup <br />a.m. Wm. <br />Start <br />112 <br />=a.m. p.m. <br />End. <br />E la.m. <br />Time <br />I, itnJ <br />/5 <br />p.m.. <br />Approximate Number of <br />Attendees <br />1 <br />Please answer the following appropriately: <br />r' <br />This event will be open to residents outside the immediate <br />[Z <br />YeEl <br />No <br />neighborhood.... <br />All residents on the affected block have been notified and invited. A <br />Yes <br />F' <br />No <br />copy of the flyer distributed is included. <br />-) <br />z <br />• There is/are resident(s) affected by the event that may need ADA <br />❑ <br />Y <br />' <br />No <br />transportation assistance to their residence. <br />This event will have music (live or other). <br />es <br />❑ <br />No <br />• Payment of $50.00 fee payable to City of South Bend included <br />Yes <br />❑ <br />No <br />" <br />Updated 08/2017 <br />