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APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO THE PUBLIC PrAC <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. <br />❑ Fee Paid <br />Applicant Name: Downtown South Bend <br />Address: 217 S. Michigan St. City: South Bend State: IN Zip: 46601 <br />Phone: 574-968-7293 Email: kcarter@downtownsouthbend.com <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 February First Fridays fireworks show <br />Location Jefferson Bridge <br />�........ ... _............. <br />(Describe Area/Route) <br />Street Closure Name of Street Jefferson Boulevard <br />From Dr. Martin Luther K.L99 Jr. Boulevard <br />To Niles Avenue <br />Date of Event February 1 20 19 <br />Time: Registration/Setup 3 0 a.m. a.m. ❑ a m EX p.m. Start 9 I] P.M. End _ 11:30 �p M. <br />Approximate Number of Attendees <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />a. I understand the Noise Ordinance described in the Agreement/Permit <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 <br />additionally filed with the Office of the City Clerk, 41" 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 />e. A copy of a flyer or door hanger that has been distributed to all <br />affected property owners. <br />3. <br />a. This event involves City streets <br />b. This event involves County roads <br />c. This event involves State highways <br />Updated 8/2017 <br />❑ Yes No <br />D Yes Ej No <br />nX <br />Yes <br />❑ <br />No <br />3 <br />Yes <br />No <br />❑ <br />Yes <br />❑ <br />No <br />® <br />Yes <br />❑ <br />No <br />❑ <br />Yes <br />X❑ <br />No <br />❑ <br />Yes <br />® <br />No <br />1 <br />