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Applicant's Legal Name <br />Business Name <br />APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />Title <br />-vilu-5 L C- - p94 <br />Address, wr+ (,� L101 <br />Telephone Number <br />Proposed Location and Description of Sidewalk Cafe <br />Days of Sidewalk Cafe Operation <br />Hours of Sidewalk Cafe Operation <br />Sun I Mon Tues <br />�1 kW�- 1413� ►owl ll�•3fl _ t(" <br />8eA •-10PVA to Ym to <br />Wed I Thurs <br />U <br />0V TH <br />Fri Sat <br />f2- Av4 12,71t <br />The following information is REQUIRED for completion of a Sidewalk Cafe Application: <br />1. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafe showing placement/dimensions of proposed <br />cafe <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend <br />as additional insured) <br />AFFIRMATION <br />1, 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. I 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 cafe as permitted herein. I do hereby certify and affirm that all the information given in this application is <br />true to he. ;crest of my knowledge. <br />Datd na of <br />ve LoWe— <br />Printed Name <br />O1n)v�d Qrer�p:� <br />WWWWWWwwww__w <br />Title._.. �. <br />4)ARD OF PUBLIC WORKS APPROVAL <br />President Member Member <br />1117A... <br />ember Member Date <br />RETURN FORM TO: 5 <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 />