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APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />DATE <br />FEE PAID <br />1 '; , � ... <br />Applicant's Legal Name - � "" 1� i Title ICA e <br />Business Name ..��_ ... .. �� �_��_��................... _�... <br />Address mow.:° 10 N' IIn 15_, t 1 .,. ' ` 1 P 3 O <br />Tele hone Number <br />Proposed Location and Description of Sidewalk Cafe <br />t n Tues Wed Thurs Fri Sat <br />Days of Sidewalk Cafe Operation � Sung �M ww� wwww _w mm w .. wwwww <br />0 <br />awl; lWi <br />Hours of Sidewalk Cafe Operation <br />The following information is REQUIRED for completion of a Sidewalk Caf6 Application: <br />1. Completed/signed application, including a S10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafe showing placement/dimensions of proposed <br />cafd <br />Completed/signed Agreement <br />Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend <br />as additional insured) <br />AFFIRMATION <br />I, the undersigned, agree that I will abide by all of the provisions of Section 18-15 of the South Bend Municipal <br />Code and with all the provisions stated above as conditions of the issuance of this Permit. 1 further agree to <br />indemnify, defend and hold harmless the City of South Bend from any liability, loss, cost, damage or expenses, <br />including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a <br />sidewalk cafd as permitted herein. I do hereby certify and affirm that all the information given in this application is <br />true to the best of my knowledge. <br />P <br />Date � � �mmm� .....Signature of AP'plac,imt__.���" <br />President <br />Member <br />Printed Name <br />._ .. ...... ........ _...... � <br />Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />Member <br />Member <br />RETURN FORM TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 • Fax: (574) 235-9171 <br />C........... . <br />ember <br />k ' <br />Date' <br />0 <br />