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APPLICATION <br />FOR USE OF, AND BLOCKING OF ACCESS TO, THE PUBLIC <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES <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 />❑ Fee Paid <br />Applicant Name: Urban Adventure Games, Inc. / Jennifer Stephens <br />Address: PO Box 11463 City: South Bend State: IN Zip: 46634 <br />Phone: 574-703-2535 Email: —jennifer@urbanadventuregames.com <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 2018 Urban Adventure Games <br />Location Wayne Street Garage - 121 E Wayne St, South Bend, IN 46601 <br />(Describe Area/Route) <br />Street Closure Name of Street Wayne St <br />From MLK Jr Blvd <br />To Michigan St <br />Date of Event Juiy 28 20 18 <br />N a, m. 0 a.m. <br />El a.m. <br />Time: Registration/Setup 5:00 n p.m. Start 8:00 E] p.m. <br />End 3:00 P.M, <br />Approximate Number of Attendees 600 <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />[X-1 Yes, n No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />FX-1 Yes El 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 5 0 1 (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 />Yes F-1 No <br />additionally filed with the Office of the City Clerk, 41h 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 />Yes No <br />c. A copy of a flyer or door hanger that has been distributed to all <br />Yes ❑ No <br />affected property owners. <br />3. <br />a. This event involves City streets <br />X Yes No <br />b. This event involves County roads <br />❑ Yes No <br />c. This event involves State highways <br />Yes No <br />Updated 8/2017 <br />