Non Res Block Party - South Bend Farmers Market - Cars and Craft Brews

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APPLICATION FOR USE OF, AND BLOCKING OF ACCESS TO, THE PUBLIC RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES 1865 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. E�/Fcc Paid ol'o Applicant Name: -361A'� Ou"Id Address: /Id,& City: 6Etc 4 e, State: IV zip: Pq Phone: Email: 5�f/j ly2q e, ol Mgt chin 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 cifi'-5 A C-(qj"f AW'q-� Location S10 11L, tL Aw� eiiJ iey-f �AA e- �4,� �11 e-y (Describe Area/Rootc) Street Closure Name of Street Frown NO Date of Event 20, t9 1&4,IVV E] pm. Start ❑ p.m. End 13,T11. Time: Registration/Setup Approximate Number of Attendees Answer the following appropriately: 1. This event will have music (live or oth9r). ❑Yes ❑ No a. I understand the Noise Ordinance described in the Agreement/Permit EP' Yes ❑ No 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-EZ are included with this application, and F-1 Yes 0/ No additionally filed with the Office of the City Clerk, 4"' Floor, County - City Building, 227 W, Jefferson Blvd., South Bend, Indiana. c. Certificate of Insurance d. Maps, drawings and setup plan of the area Yes ❑ No c, A copy of a flyer or door hanger that has been distributed to all Yes No affected property owners. 3. a. This event involves City streets 1Z Yes No b. This event involves County roads F] Yes No c. This event involves State highways El Yes ❑No Updated 8/2017