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APPLICATION FOR S'IDEWAI,i'^iw, CAFE: PERMIT <br />DATE CITY OF SOUTH BEND, INDIANA <br />� � t�l <br />Applicant's Legal Name ct) r � e X& Title <br />Business Name_, <br />Address <br />Telephone Number <br />1. <br />m'1 <br />FEE PAID $ <br />Q <br />14- �3 k(r?3�-11� <br />Proposed Location and Description of Sidewalk Caf6: <br />Days 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 $3001000/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 the best of my knowledge. <br />Date Signature of Applicant. <br />,P <br />Printed Name <br />BOARD OF PUBLIC WORKS <br />Cry A. Glot. P' si&nt <br />LI .MI,A M U, ll—b©e <br />I nq,h R. Molnar. Mem},, <br />Title _..0 <br />`i ",.,.bt,"i9v..,,,..,. <br />lb ­ 7 [). a , Mnnbn <br />7(d- \. Whrn M—b©, <br />AffLSI <br />ec'.A,chfmm, <br />Lind. M. Maehv, CIA, <br />RETURN FORM TO: 4 <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 />