Non Res Block Party - VPA - Tree Lighting Ceremony

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U" 1� %fr The Board of Public Works must have FOUR (4) weeks Prior notice of the event. A NON-REFUNDABLE APPLICATION FE, E 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. Ll Fee Paid Applicant Name: pn n Address: 30 J�C. �,&d U;S _5MJ4�14tate: Zip: _5661 -3 Phone: 5-7 2_15 _ Email: 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 %& Location Street Closure Name of Street b 1 1 M. �r F, %a - C I From To Date of Event F1 RegistratiOn/Sctul? 21p.m. 'Start p.m. ❑a,m End p.m. Time: Approximate Number of Attendees Answer the following appropriately: yes ❑No 1. This event will have music (live or other). No I understand the Noise Ordinance described in the Agreement/Permit Yes a. 21 Required Inforination 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 Yes Fj No Form 990 of Form 990-EZ are included with this application, and 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 Yes D No d, Maps, drawings and setup plan of the area e. 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 Yes E] No [:1 No This event involves County roads Yes Yes El No This event involves State highways El Updated 8/2017 A