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APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC <br />RIGHT-O&WAY FOR A RESIDENTIAL BLOCK PARTY <br />The Board of Public Works must have four (4) weeks 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 />Organization-, <br />State: <br />zip <br />Address:13 <br />e) f. ds <br />_LX'_VL/ <br />4 <br />1111 61 w <br />Phone: <br />5­7 / Email. Z11 <br />-e .6na-) <br />y 4/0 V '3 4/ 2_91 1016)12eop-)1412, t. <br />...... ..... . . <br />Secondary Contact <br />Address: <br />cp 1 <br />city: 50, t3,t State: <br />Phone: Email: <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of <br />the speciffiedpubli rigijhj�t-oif-way by Applicant for the holding of the hereinafter described event. <br />Event Name <br />Street Closure <br />Name of <br />Street <br />From <br />ohve <br />To <br />Date of Event <br />S, <br />20 <br />Time <br />S <br />❑Start <br />Will, EIP-m. <br />End <br />V 1 <br />Da.m. El <br />Time <br />Time <br />Approximate Number of <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate <br />El <br />Yes <br />E] <br />No <br />neighborhood. <br />• All residents on the affected block have been notified and invited. A <br />EF <br />"Yes <br />❑ <br />No <br />copy of the flyer distributed is included. <br />• There is/are resident(s) affected by the event that may need ADA <br />F-1 <br />Yes <br />M-'No <br />transportation assistance to their residence, <br />I <br />• This event will have music (live or other). <br />tM <br />'Yes <br />Ze <br />Ej <br />No <br />• Payment of $50,00 fee payable to City of South Bend included <br />s <br />s <br />E] <br />No <br />�dlllll) <br />Updated 08/2017 1. <br />/ . . ....... <br />