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APPLICATION FOR SIDEWALK CAFE PERMIT CITY OF SOUTH BEND, INDIANA DATE Applicant's Legal Name �+L Title w Business Name Address 1w, roA4 V" FEE PAIDp e" Telephone Number w- m mmmm - c, p _ _ _.�v_ �� . _....�................................... ...... _... ...m.._........ � W. Proposed Location and Description of Sidewalk Caf6 Days of Sidewalk Cafe Operation I Sun Hours of Sidewalk Cafe Operation 0 Mon I Tues V Wed m Thurs Fri Sat l� !L n°AA, 171 �0 The following information is REQUIRED for completion of a Sidewalk Caf6 Application: 1. Completed/signed application, including a $10.00 fee 2. Drawing(s) and description of proposed sidewalk caf6 showing placement/dimensions of proposed caf6 3. Completed/signed Agreement 4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend as additional insured) AFFIRMATION 1, the undersigned, agree that I will abide by all of the provisions of Section 18-15 of the South Bend Municipal Code and with all the provisions stated above as conditions of the issuance of this Permit. I further agree to indemnify, defend and hold harmless the City of South Bend from any liability, loss, cost, damage or expenses, including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a sidewalk caf6 as pennitted herein. I do hereby certify and affirm that all the information given in this application is true to the best of my knowledge. r Date Signature of /,�llicant g ll Printed Name Title BOARD OF PUBLIC WORKS APPROVAL President Member Member Member � �.� _......�................ .... .... �...... �. - � . n Member Date RETURN FORM TO: 4 Board of Public Works 1316 County -City Building 227 West Jefferson Boulevard South Bend, 1N 46601 Phone: (574) 235-9251 o Fax: (574) 235-9171