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RECEIVED <br />U1IYUF6VUIt, <br />t <br />DIV, OF FN(71NFFQi�,r.; <br />DATE f&V <br />APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />rr\\ +e'tGs <br />FEE PAID K$ L V. L(�, <br />0-A-got--,HA-M � L� <br />Applicant's Legal Name E P_ ��� �]' /J.#C'_ .Title <br />Business Name j � <br />Address MA/ ,, r 1 I <br />. Iy � CJ t . SO LLz-�• its i~D� <br />Telephone Number 7 <br />Proposed Location and Description of Sidewalk Cafe <br />St )7 Iti1 N 1 _ ,/ / hA KA Ara L.V / 1--� T--Z!16-M -QAS I l,J l � <br />Days of Sidewalk Cv: f6 Operation <br />Hours of SidewalkCaf60peration <br />Sun <br />Mon <br />Tues <br />Wed <br />Thurs <br />Fri <br />Sat <br />/1�►►�- <br />11 AM <br />///"- <br />PYYt <br />l/gym- <br />IIAYX- <br />1p`2 <br />//,46t- <br />IIAM <br />t;2AYW <br />The following information is REQUIRED for completion of a Sidewalk Caf6 Application: <br />l . Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafe showing placement/dimensions of proposed <br />caf6 <br />3, Completed/signed Agreement <br />4. Certificateoflnsurance($1,000,000/occuranceand$300,000/person,namingthe City ofSouth 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 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 />Date <br />&:t�oa.a <br />Signature of pplicant 1 <br />W EF�A-/V - <br />Printed Name <br />Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />BOARD OF PUBLIC WWOOyR,—KfSS <br />Q" <br />eiAun.�e-odvw. <br />Gmy A. Gd.t, I .dent <br />Tb— J. Dm Member <br />Eliubeth A. Maradik, Member <br />Jordan V. Gathm, Member <br />ATTEST: <br />Joseph R. Molnar, Member <br />RETURN FORM TO: <br />Linda M. Martin, Cledc <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 />