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APPLICATION <br />FOR USE OF, AND BLOCKING OF ACCESS TO, THE PUBLIC <br />RIGHT -,OF -WAY FOR NON-RESIDENTIAL BLOCK PARTIES <br />The Board of Public Works must have FOUR (4) weeks prior notice of the event, <br />A NON-REFUNDABLE APPLICATION FEE OF $125.00, 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:v) f�rd Vee�Paid <br />If <br />Address: pity: Zip: <br />dPhone: 7 0 Email: <br />-e <br />This application is made to the City Of South Bend, Indiana, Board of Public Works, for the use of the <br />specified public right-of-way by Applicant for the holding of the hereinafter described event: <br />t A <br />Event Name N Pelv KNA 11 V I <br />Location <br />"— I <br />ST. <br />(Des4ribe Area/Route) <br />Street Closure Marne of Street <br />From MR <br />To 0 fcAn <br />Witaw0 Date of Event y 1� �71. r a.m. F] a.m. <br />Time: Registration/Setup 0- F-1 p.rn. Start p.m. End <br />Approximate Number of Attendees <br />Answer the following appropriately: <br />I , This event will have music (live or other). <br />Yes F-1 No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />Yes ❑ No <br />2. Required Information to Accompany Application <br />a. Certified Check or Money Order in the Amount of $125.00, or: <br />b. For Certified Nonprofit Organizations: Copies of the 501 (c)(3) <br />Internal Revenue Exemption Status Document and a current copy of <br />Form 990 of Form 990-EZ are included with this application, and <br />Yes ❑ No <br />additionally filed with the Office of the City Clerk, 4"' Floor, County - <br />City Building, 227 W. Jefferson Blvd,, South Bend , Indiana. <br />c. Certificate of Insurance <br />d, Maps, drawings and setup plan of the area <br />Yes No <br />e. A copy of a flyer or door hanger that has been distributed to all <br />Yes ❑ No <br />affected property owners. <br />3. <br />a. This event involves City streets <br />[R( Yes E] No <br />b. This event involves County roads <br />E] Yes No <br />c. This event involves State highways <br />❑ Yes No <br />Updated 8/2017 <br />1 <br />