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APPLICATION FOR SIDEWALK CAFt PERMIT <br />DATE Zfi�IZO CITY OF SOUTH BEND, INDIANA <br />FEE PAID <br />Applicant's Legal Name V071 LL�itle JJ I c-Tor q <br />1 <br />Business Name Alm" Rol ll—h R p rl rl <br />Address I I, I Nor i W 0 i <br />Telephone Number 5 1 q — 00 <br />Proposed Location and Description of Sidewalk Cafe <br />a <br />w <br />IN65 <br />Days of Sidewalk Cafe Operation <br />of Sidewalk Cafe Operation <br />Sun <br />Mon Tues <br />Thurs <br />Fri <br />SatHours <br />10-10 <br />EWe <br />i, ' I <br />+It `1-1( <br />H —I 1 <br />+1 1 <br />16— I I <br />The following information is REQUIRED for completion of a Sidewalk Cafe Application: <br />1. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk caf6 showing placement/dimensions of proposed <br />caf6 <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($ 1,000,000/occurance and $ 3 00,000/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 />2t <br />Date � ��� <br />Lg-ea <br />gutf Applicant <br />Gmank MWO, <br />Printed Name <br />BOARD OF PUBLIC WORKS APPROVAL <br />BOARD Ole PUBLIC WORKS <br />Gary i (IoL P-,id-t <br />11 •row J D M-1— <br />— <br />F mA 1, 1 '&,,Idik, M..bcI <br />i �dn V. O Ih NI—bcr <br />AIATSL <br />_._ <br />loscryt R Yt ilon�, t9emba <br />Lmd.m M tm,cl�A <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 />