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A PPjACATION IFOR SIDEAVALK CAF, tPERMIT <br />DATL C rry OF SO( IT 11 BEND, I NDIANA <br />Applicant's Legal Name <br />Business Name <br />Address <br />Telephone Number <br />-�-"Orapw� Title <br />Proposed Location and Description of Sidewalk CaR <br />�r-\ 6r07 & f6 <br />Days of Sidewalk Caf& ,cralion Sun Mon <br />Houm of Sidewalk Caf6 tion I.- ',, I la-31 <br />orb <br />F `E' P A 11) $ <br />Tues I Wed I Thurs I Fri I Sat <br />�'9 1 <br />Thefollowing informationis REQUIRED for coin pletion of a Sidcwa Ik Caf& Application: <br />I. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk caf6 showing placement/dirnerisions of proposed <br />caf6 <br />3, Completed/signed Agreement <br />4. Certificate of Insurance(S 1,000,000/occurance and $300,000/person, naming the City of South Bend <br />as a d ditiona l 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 caf6 as permitted herein. I do hereby certify and affirm that all the information given in this a hcation is <br />true to th e best of my knowledge. <br />DaSiga at i6 o fApplicant <br />Printed Name <br />Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />WARD Of PUBLIC VN OMCS <br />G— A, (hk'L <br />-I- <br />Fli"I"ll'A' ma-rk M—b" <br />Al IMI <br />""'h RzM-1- <br />Lmd� M d- <br />RETURN FORM TO: 4 <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefl'Qrson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 * Fax: (574) 235-9171 <br />