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{ k4 I APPLICATION FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC *' BIGHT -OF -WAY FOR A RESIDENTIAL BLOCK PANTY 186 The Board of Public Works must have four (4) weeps prior notice of the event. NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED CHECK. OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. Applicant Name: l D"b P Organization: � �" C)r"r)(E-, OW ne t' Asoo CkAi Oil • O wc)() C a qc '6 !�� State: p W Address: A Phone:J � � y 1�"n1 11: Sewn,aary Contact _ S C E , Address: _ )S City: State: Phone' - q60 — 0,309 Email: This application is trade 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 * V._ � Street ll f;,' r) Gxm016SWDriw ail TljrA) Street Closure A.i)r' From � : O PM OJOierX0 - daR To oo u . — cU I X Date of Event 0 C: 4 , 20 Time Setup ❑a.r , M. Start oo �.m. M. End 5, 00 ©a.m." a.m. d � .Tune Time i Approximate Number of Attendees Please answer the following appropriately: • This event will be open to residents outside the immediate ❑ Yes No neighborhood. • All residents on the affected block have been notified and invited. A Yes, No copy of the flyer distributed is included. • There is/are resident(s) affected by the event that may need ADA ❑ Yes No transportation assistance to their residence. • This event will have music (live or other). `des No • Payment of $0.00 fee payable to City of South Bend included Yes No Updated 08/2017