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APPLICATION <br />% <br />FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC <br />RIGHT, -OF -WAY FOR A RESIDENTIAL BLOCK PARTY <br />The Board of Public Works must have four (4) weelo prior notice of the event. <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 />r1 v \1 ( -�Ckp 4� <br />Organization: <br />d"A E. Endlavia'- A-Ve' <br />City: <br />T <br />St±t'( <br />Zip <br />Address: <br />Phone: <br />Email: <br />Secondary Contact ly-\ <br />Address: Arn A c� 6�- 9 1 <br />City: State: <br />Phone. Email: -tt J <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of <br />the specified public ri ht-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name <br />VQ cc, n <br />Nameof <br />S4 � ()-� h S+ <br />Street Closure <br />Street <br />-,p <br />From <br />J:(N C1 I CC n <br />To <br />f I <br />r, an ey <br />Date of Event <br />ikj. '0— 1 <br />201 <br />-1, <br />Time <br />etup <br />Da.m. E�fi-tn. <br />Start <br />11a,m. PP-M. <br />End <br />ilbco) <br />El a <br />0'm' . m, <br />Time <br />Time <br />� <br />P�m- <br />Approximate Number of <br />Attendees <br />Please answer the fallowing <br />• This event will be open to residents outside the immediate <br />0 <br />Yes <br />El <br />No <br />neighborhood. <br />• All residents on 11 the affected block have been notified and invited. A <br />FA <br />Yes <br />0 <br />No <br />copy of the flyer distributed is included. <br />-7Z <br />• There is/are resident(s) affected by the event that may need ADA <br />El <br />Yes <br />No <br />transportation assistance to their residence. <br />This event will have music (live or other). <br />❑ <br />Yes <br />16 <br />No <br />Payment of $50.00 fee payable to City of South Bend included <br />Yes <br />No <br />cc 1, ne+ <br />Updated 0 8/2 0 17 <br />