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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. EeFcc Paid /"6rm <br />Applicant Name: T)Ow <br />ey' <br />Address: <br />?0-7LnMWS City: State: Zip: Akov— <br />maly- <br />Phone: �3- �6'?p Email: �r- <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 />Event Name <br />Location A'W'--'A5 <br />(Describe Area/Route) <br />Street Closure Name of StTect UPW&AVa'As <br />From <br />To <br />Date of Event W-14— 20 <br />R -a" M. <br />Time: Registration/Setup a; o 0 El pm- Start 1: 06 E] p.m. End M-P-1-Imm"'. <br />Approximate Number of Attendees C—L> VL4VV— <br />Answer the following appropriately: <br />1. This event will have music (live or other), Yes No <br />a. I understand the Noise Ordinance described in the Agreement/P'ermit Yes F-1 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 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 No <br />e. A copy of a flyer or door hanger that has been distributed to all Yes No <br />affected property owners. <br />3. a. This event involves City streets Yes ANo <br />b. This event involves County roads ❑ Yes No <br />c. This event involves State highways Yes No <br />Updated 8/2017 1 <br />