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APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />DA 11? N �) FEE PAID <br />Applicant's Legal Name <br />Business Name <br />Address <br />Telephone Number Sr)(`) 2— <br />Proposed Location and Description of Sidewalk Cafd <br />Title 6 t__0 Vl cv', <br />&P <br />Days of Sidewalk Cafd Operation Suit I Nion I Tues I Wed I -fhurs Fri Sat <br />Hours of Sidewalk Cafd Operation — 11 - ( 1((p 4_A <br />The following information is REQUIRED for completion of a Sidewalk Cafd 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 />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 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 />F <br />N ' Maturof A <br />Date e pp cant <br />I <br />Printed Name wm ry <br />Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />BOARD OF PUBLIC bt ORKS <br />s_,v 61,, <br />Gary,A. (filot,President Therese I. Doug Member <br />—taA)_ aL, %, .Xl;, <br />RETURN FORM TO: 4 <br />��- 77- ATTLST: Board of Public Works <br />1316 County -City Building <br />°bu eP(�irr 227 West Jefferson Boulevard <br />Joseph R.MoInar°member - South Bend, IN 46601 <br />Lindalt.ta n,Cerk Phone: (574) 235-9251 • Fax: (574) 235-9171 <br />7 <br />