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r� , <br />- y OVA k <br />APPLICATION FOR SIDEWALK CAFE PERMIT f� <br />C O S B I a <br />ITY F OUTFI END, NDIANA <br />DATE _ FEE PAID <br />Applicant's Legal Name ..�.a_ �Title <br />Business Name., <br />Address.:; , �. ..�..." 7�., <br />Telephone Number <br />Proposed Location and Description of Sidewalk Cafe <br />Days of Sidewalk Cafe Operation d Sun Y Mon 9 Tues I Wed I Thurs I Fri Y Sat <br />Hours of Sidewalk Cafe Operation <br />The following information is REQUIRED for completion of a Sidewalk Caf6 Application: <br />1. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk caf6 showing placement/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, 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 caf6 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 Sign ture o A licant <br />�) d^ <br />Printed Namev <br />Title <br />BOARD OF PUBLIC WORKS APPROV <br />. . .. �, V� tt <br />President 6" etl be eillber <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 r Fax: (574) 235-9171 <br />ti <br />Date <br />2 <br />