Non Res Block Party - Murray Miller - Back to School Rally

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APPLICATION FOR USE OF, AND BLOCKING OF ACCESS _E PUBLIC The Board of Public Works must have FOUR (4) weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. J El Fee Paid Applicant Name: FITARM 0 z"k 'I I -3� soe'3' Address: 0. 13 City: /3e,4,>/)State: zip: Phone: i i / X 6 i 9) e,,,,, Email: This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name Dweh- 76--7 Sc) 0c, Location 2&,4 leCA-) (Describe Area/Route) Street Closure Name of Street From ealle * e To Aied&'e Date of Event &: �g! t.� g 7 1/ 20 I v , F-1 a.m. Time: Registration/Setup t,,00 E-1 p.m. Start f.Mej Elp.m. End 0,z:jo R—p.m. Approximate Number of Attendees 26-e> Answer the following appropriately: 1. This event will have music (live or other). Yes ❑ No a. I understand the Noise Ordinance described in the Agreement/Permit R Yes El No 2. Required Information to Accompany Application a. Cettified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies of the 5 01 (c)(3) Internal Revenue E3 emption Status Document and a current copy of Form 990 of Form 990-EZ are included with this application, and Yes No additionally filed with the Office of the City Clerk, 4"' Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana, c. Certificate of Insurance d. Maps, drawings and setup plan of the area Yes No e. A copy of a flyer or door hanger that has been distributed to all Yes No affected property owners. 3. a. This event involves City streets Yes F-11 No b. This event involves County roads El Yes R No c. This event involves State highways El Yes No Updated 8/2017 1