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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 />❑ Fee Paid <br />Applicant Name: f <br />Address: a � � <br />r(1 +M�ckt,�� ,� City: ::�'• State: -_­S:7� Zip: k4 (0(0 <br />J._ <br />Phone: Email: " - � `� ' 1N,c CQ (`-te S . 0_"_ <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use ohe <br />specified public right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name ' 1y���-� C o<\ U C ' a <br />Location cr(-\ q? `w C�r t. F, <br />1tv� (Describe Area/Route) <br />Street Closure Name of Street C�,_ 'C--, -� <br />From 17 V-� <br />To <br />Date of Event 9L 20 L <br />❑ a.m. ❑ a.m. <br />Time: Registration/Setup S' 3 U gp.m. Start L";. _ UC) _Pl.m. <br />Approximate Number of Attendees <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />2. Required Information to Accompany Application <br />a. Certified Check or Money Order in the Amount of $125.00, or: <br />93 <br />� ❑ End OfQ-grin. <br />Ef Yes ❑ No <br />❑' Yes ❑ No <br />b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) <br />Internal Revenue Exemption Status Document and a current copy of <br />Forth 990 of Form 990-EZ are included with this application, and ❑ Yes No <br />additionally filed with the Office of the City Clerk, 41h 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 />e. A copy of a flyer or door hanger that has been distributed to all <br />affected property owners. <br />a. This event involves City streets <br />b. This event involves County roads <br />c. This event involves State highways <br />Yes ❑ No <br />❑ Yes El" No <br />Yes <br />❑ <br />No <br />❑ <br />Yes <br />No <br />❑ <br />Yes <br />Er <br />No <br />Updated 8/2017 <br />