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APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />I <br />DATE FEE PAID ❑ $ <br />Applicant's Legal Name F 1���-ar Title �Q er Z'/i'l�/fir/ <br />Business Name <br />Address L 1C be /9/4,� �u , °� 1" e'^al l�f <br />Telephone Number �'J y _ y _ cJ (� c 0 61 <br />Proposed Location and Description of Sidewalk Cafe <br />Days of Sidewalk Cafe Operation <br />Sun <br />Mon <br />Tues <br />Wed <br />EThurs <br />FriSat <br />Hours of Sidewalk Cafe Operation <br />(v <br />cep lY� <br />�� LJ��~ <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 />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 a ffimi that all the information given in this application is <br />true to the best of my knowledge. <br />ia- ;0 j) <br />Date signatfofA. 1 •ant <br />r � ElI't P 6 <br />Printed Na e <br />Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />I3 ARD OLD PlPUBIAC WORT{S <br />G,V A. Gl,t, Pr,,idnv <br />Jbcv ese 1 1Joray Rfombcr <br />Efi ebcfhA M Lk i-1- <br />[� <br />R-1- V 6.1hm M-1- <br />c2nwA offmtnr <br />1A,R NMI Mr bc, <br />- <br />Linde �! �S rhn. le�'k <br />C Lin <br />_ <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 />M <br />