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t rwken <br />APPLICATION FOR SIDEWALK CAFt PERMIT <br />'( CITY OF SOUTH BEND, INDIANAs <br />DATE _ ......... _ _ FEE PAll.1 $- � <br />Applicant's Legal Name [(� 1 - Title rn <br />Business NameF <br />�- <br />Address <br />Telephone Number 7%) % <br />Proposed Location and Description of Sidewalk Cafe <br />.: „ <br />Days of Sidewalk Cafe Operation Sun Mon Tues Wed Thurs Fri Sat <br />Hours of Sidewalk Cafe Operation - G- G : �6- -, (3l1_. 7 — R <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 the best of my knowledge. <br />Date Signature of pplicaltt <br />t. 1 <br />Printed Name <br />a. .. . ......... _........... �. Title �� <br />BOARD OF PUBLIC WORKS APPROVAL <br />President Member Member <br />�.. <br />Nfember Member Dat <br />w <br />RETURN FORM TO: 4 <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 />