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APPLICATION FOR SIDEWALK CAF t PERMIT � w <br />CITY OF SOUTH BEND, INDIANA 61 <br />DATE FEE PAID <br />Applicant's Legal Name q? I ro s ' w Title <br />Business Name k A '_ �- i e <br />Address <br />Telephone Number /" 1) `:� (..t ) l" Y °— <br />Proposed Location and Description of Sidewalk Cafe <br />Days of Sidewalk Cafe Operation <br />Hours of Sidewalk Cafd Operation <br />Sun <br />Mon <br />Tues <br />Wed <br />Thurs <br />Fri <br />Sat <br />- <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 cafd showing placement/dimensions of proposed <br />cafd <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, 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 />J <br />Date ` 'igna acre of Applicant <br />NNIN <br />^., . <br />Printed Name <br />'Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />President Member Member <br />Member 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 />Date <br />4 <br />