Laserfiche WebLink
R <br />M.WME . <br />IMULK-1 01 1, 1 11,WAMjMiW <br />W1#1jD1 <br />TM., N-jEly, <br />j I JrJL -JE-9-111- <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 />INCLUDED WITH APPLICATION. <br />F1 Fee Paid <br />Applicant Name: bv)"Av \(`kl <br />Address: (`)0\, City: o,5,,-:," <br />State: N Zip: <br />Phone: Email: <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: <br />Event Name <br />Location V 6 G (­ r dll, <br />(Describe Area/Route) <br />Street Closure Name of Street <br />From 'S h C.(,k N, <br />To tfl'Qry\OLk�, <br />Date of Event '�IUAII 20 <br />a. M. a.m. <br />V� 9p.m. <br />a.m. <br />End <br />Time: Registration/Setup E] p... Start <br />P.M, <br />Approximate Number of Attendees <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />Yes No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />Yes 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 Organizations: 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 />0 Yes No <br />additionally filed with the Office of the City Clerk, 4 1h 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 />El Yes El No <br />c. A copy of a flyer or door hanger that has been distributed to all <br />Ej Yes R No <br />affected property owners. <br />3. <br />a. This event involves City streets <br />Yes No <br />b. This event involves County roads <br />❑ Yes No <br />c. This event involves State highways <br />❑ Yes No <br />Updated 812017 <br />