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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 -RE FUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED <br />CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUS­ <br />INCLUDED WITH APPLICATION. <br />[V,47c c Paid ✓ dG, <br />T( Applicant Name: VL4 V1 rOl <br />Address: q n §hzity: wdiAMOD I (� State: -1 Zip: 104- <br />Phone: �11-6100-�i wo Email: +-foydftft�vel�- �M� <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 -�- I o�-' - a - Tye 0 � <br />Location edh S-k mmws <br />(Describe Area/Route) <br />Street Closure Eddu <br />Name of Street <br />eM C <br />To rIFrom <br />N(4%0 (e Q n <br />Date of Event 20 M <br />F-11 a.m. F-1 m .m� <br />Time: Registration/Setup MP.M. Stall <br />El a.m. <br />End 16 N?rp.t. <br />Approximate Number of Attendees <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />Yes No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />Yes D 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 50 1 (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 <br />Yes ❑� No <br />additionally filed with the Office of the City Clerk, 4,h 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 />Yes ❑ No <br />c. A copy of a flyer or door hanger that has been distributed to all <br />Yes ❑ No <br />affected property owners. <br />a. This event involves City streets <br />Yes ❑ No <br />b. This event involves County roads <br />El Yes No <br />c. This event involves State highways <br />E] Yes No <br />Updated 8/2017 <br />1 <br />