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APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />DATE � 4 <br />Applicant's Legal Name <br />Business Name <br />Address <br />Telephone Number <br />Proposed Location and Description of Sidewalk Cafe <br />Days of Sidewalk Cafe Operation I Sun <br />Hours of Sidewalk Cafe Operation <br />Mon Tues 1I Wed <br />FEE PAID $_�- <br />Thurs 1' Fri I Sat <br />Lt� ( L 1 ., <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 placeanent/dimensions of proposed <br />caf6 <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 />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. I further agree to <br />indemnify, defend and hold harmless the City of South Bend from any liability, loss, s $W-r4p rntagc; or expenses, <br />including attorney fees, which the City may suffer or in r as the result of any s tia ttlalic sidewalks for a <br />sidewalk cafe as permitted herein. I do hereby certify as d s� tira n that al l�a in��atit gym' eawn in this application is <br />true to the best of my knowledge. ,4 6 11 <br />........... . U1 <br />Date Signatu <br />Printed Natlie <br />Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />President ember Member <br />�.� <br />Member Member Date <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 9 Fax: (574) 235-9171 <br />