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APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC <br />RIGHT-OF-WAY FOR A BLOCK PARTY <br />ALL APPLICATIONS MUST BE RECEIVED BY THE BOARD OF PUBLIC <br />VAT 'rV0 THAN FOUR 4 I 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 />Naive: <br />Address: City: State: Zip <br />Phone: Email: <br />Date of Event _ 20 from <br />Nance or Type <br />of Event <br />a.m. /p.m. to <br />a.m. /p.m. <br />Approximate Number of Attendees <br />Location from <br />to <br />Street Name Goss Street <br />Cross Street <br />Please answer the following: <br />• This event will be open to residents outside the <br />immediate ❑ <br />Yes ❑ No <br />neighborhood. <br />• All residents on the affected block have been notified. <br />❑ <br />Yes ❑ No <br />• This event will have music (live or other). <br />[] <br />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 $400.00 roust be submitted with application ❑ <br />• Application cannot he processed without di,,posi't. <br />+ Deposit will he ren(med upon inspection ofevent area by the Board of Public Works•. <br />Names and phone numbers of THREE security guards. ❑ <br />• <br />To monitor underage drinking. <br />• Qualifications inust be listed (e.g. Of) =dut} police orfice), professio►trrl ,securih rcGrr,d, or <br />ewnt APPLICANT). <br />A drawing must be submitted showing: ❑ <br />• Fencing around sen ?rng area. <br />• Trash receptacle. <br />o Ample trash receptacles oust be provided to ensure proper disposal vfrefuse. <br />Temporary liquor license ❑ <br />• Call the Alcohol & Tobacco Commission at (317) 232- 2430.1br more iifarmalion, <br />• Applieittion cannot he processed without a copy of this license. <br />