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�OUZ � <br /> APPLICATION <br /> FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC <br /> RIGHT-OF-WAY FOR A BLOCK PARTY w a eE 'J <br /> ALL APPLICATIONS MUST BE RECEIVED BY THE BOARD OF PUBLIC WOK _is6s <br /> NO LATER THAN FOUR(4) WEEKS PRIOR TO THE DATE OF THE EVENT. <br /> THERE IS A NON-REFUNDABLE APPLICATION FEE OF$25.00 PAYABLE TO THE <br /> "CITY OF SOUTH BEND, INDIANA" TO COVER ADMINISTRATION COSTS FOR <br /> PROCESSING THE PERMIT. THE APPLICATION FEE MUST BE PAID AT THE <br /> TIME OF APPLICATION. <br /> Applicant <br /> Name: <br /> Address: City: State: zip <br /> Phone: Email: <br /> Date of Event 20 from a.m./p.M. to a.m./p.m. <br /> Name or Type <br /> of Event <br /> Approximate Number of Attendees <br /> Location from to <br /> Street Name Cross Street Cross Street <br /> Please answer the following: <br /> • This event will be open to residents outside the immediate ❑ Yes ❑ No <br /> neighborhood. <br /> • All residents on the affected block have been notified. ❑ Yes ❑ No <br /> • This event will have music (live or other). ❑ Yes ❑ No <br /> • Payment of$25.00 fee payable to City of South Bend,Indiana included ❑ Yes ❑ No <br /> IF ALCOHOL IS TO BE SERVED OR SOLD <br /> Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ <br /> Certified Check or Money Order for$40Q00 must be submitted with application ❑ <br /> • Application cannot be processed without deposit. <br /> • :Deposit will be returned upon inspection of event area by the Board of Public Works, <br /> Names and phone numbers of THREE security guards. ❑ <br /> • To monitor underage drinking. <br /> • Qualifications lnust be listed(c.g. Off-chn),police officer,prgfessional security guard, or <br /> e>>ent APPLICANT}. <br /> A drawing must be submitted showing: ❑ <br /> • Fencing around sensing area. <br /> • Trash receptacle. <br /> o Ample trash receptacles must be provided to eitsitre proper disposal of refuse. <br /> Temporary liquor license ❑ <br /> • Call the Alcohol& Tobacco Commission at(317)232-2430,for more it farnuttion, <br /> • Application cannot he processed without a copy of this license, <br />