Non Res Block Party - Kite Realty - ND Pep Rally

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APPLICATION FOR USE OF, AND BLOCKING OF ACCESS TO, THE PUBLIC RIGHT-OF-WAY FOR NON -RE, SIDENTIAL BLOCK PARTIES The Board of Public Works must have FOUR (4) weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION, P-ee Paid Applicant Name: t v V V I Address: Ir4100f(�ity: jn&&jaV1A 045State: Zip: 1 A) Email: 4-ffVd P kIA'OYM ( 'I I . O�M Phone: ft 1 &1 This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name On Dame V"'q U119 Location Emd 00 Street Closure Narne of Street From To Date of Event 1901V '7 20 M a.m. Time: Registration/Setup ❑ P.M. Approximate Number of Attendees _ F-1 EIJIL Start 7P.m. End Answer the following appropriately: I , This event will have music (live or other). a. I understand the Noise Ordinance described in the Agreement/Permit 2. Required Information to Accompany Application a. Certified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies of the 501 (c)(3) Internal Revenue Exemption Status Document and a current copy of Form 990 of Form 990-E-Z are included with this application, and additionally filed with the Office of the City Clerk, 0' Floor, County - City Building, 227 W. Jefferson Blvd., South Bend , Indiana. c. Certificate of'Insurance d. Maps, drawings and setup plan of the area e. A copy of a flyer or door hanger that has been distributed to all affected property owners. 3. a. This event involves City streets b. This event involves County roads c. This event involves State highways Updated 8/2017 e Yes Yes / Yes El M. ❑ No El No F-1 No Yes ❑ No Yes No Yes F-1 No ❑ Yes No El Yes No I