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0-� <br />APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO PUBLI, <br />RIGIIT-OF-WAY FOR A RESIDENTIAL BLOCK PART <br />The Board of Public Works must have four (4) weeks prior notice of the event. <br />A NON -RE FUNDABLE 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 />TNCLUDED WITH APPLICATION. <br />Applicant Name: <br />Organization: <br />Address: <br />City: <br />61v JIX <br />State', <br />zip <br />Phone: <br />Email'. <br />Z2 9" <br />Secondary Contact <br />Address: <br />City: State: <br />Phone: Email: <br />This application is made to the City of South Bend, Indiana, Boar o ublic Works, for the use of <br />the specified ublic right-of-wayb A licant for the holdin of the h reinafter described event: <br />Event Name <br />Name of <br />Street <br />Street Closure <br />From <br />To <br />Date of Event <br />20 <br />Time <br />�Pa,m. ElIp.m� <br />Start <br />..,,jUa—.m.E1Pm. <br />", <br />X) <br />End j <br />Ela.rn, 11A <br />P.M <br />Time <br />Time <br />Approximate Number of <br />Attendees <br />") <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate <br />Yes <br />F1 <br />No <br />neighborhood. <br />• All residents on the affected block have been notified and invited. 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 />Yes: <br />No <br />Payment of $50.00 fee payable to City of South Bend included <br />Yec s s <br />❑ No <br />Updated 08/2017 <br />