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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 />1865, <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 />r,�, ar +.AA)r_(1" , fir` 4 hb <br />Organization: <br />J 1 <br />A0 7 <br />XVV <br />City: <br />State: <br />Address: <br />Phone: <br />9?41" o2 3,,Z Email: /inn or'ne.c." 4Dr G t7&,;,r 1tPr t <br />Secondary Contact ItJ A <br />Address: <br />City: 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 s �ecified public right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name <br />r l r ,r 4gr?zs <br />Street Closure <br />Nameof <br />St r er <br />14,rfi11A ke <br />TO <br />po rA / ! <br />Date of Event <br />�p <br />20 <br />Time <br />Setup <br />0 % �� <br />.9a.rn. ©p.r�l. <br />Stan <br />1 ! ' Dd <br />�.m. ®p.rm. <br />End <br />a.m. <br />Time <br />Trine <br />p.m. <br />Approximate Number of <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate <br />Yes <br />❑ <br />No <br />neighborhood. <br />• ,All residents on the affected block have been of d an i vited A <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 />❑ <br />Yes <br />No <br />transportation assistance to their residence. <br />• This event will have music (live or other). <br />I Yes <br />No <br />• Payment of $50.00 fee payable to City of South Bend included <br />0 <br />Yes <br />No <br />lvlpq <br />Updated 08/2017 <br />