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APPLICATION FOR PLACEMENT OF <br />/ HONORARY SIGN AND OTHER HONORARY FEATURE <br />WITHIN THE PUBLIC RIGHT-OF-WAY OR ON PUBLIC PROPERTY <br />For Office Use Only: 0 Application Complete O Fee Received O Petition Complete <br />Comm ents:. ______________________________ _ <br />□APPROVE □DENY <br />1. Applicant Inform <br />� <br />j <br />� <br />' Q 6/4 12.( <br />Appl�cant's Name: �';t(IJ?V' 1/�Vrq�<( \j_ __ � Date: ___ rl� __ _ <br />Apphcant'sAddress�� ij%ff/,l}2. • IYEmail Address: ___________ _.,,. __ Telephonefm� zl), � #-/Yh15@£?1Jf/W&rfl...Yd; &DV 2.Honorary Sign or Feature Request: ______________________ _2-, ,/>.. ___ r . a--� �--nJ /Z/�I-Proposed Location: -/N�{'J <;.$(, / l-1:xa;:;;l. /. C1Jr11er ofNur1h and South Street Example <br />1: MalnStrJJutfrom /st Street lo 3rd Street) <br />Significance of Location to Honoree's Life:� /y',fp{J,(12 15-= ;1/(t,j< {!6f\)7ci{<_( Fa£AAff1Z_ Crr/ e-,«;?Ltl7G?-j <br />3. Required Submittals: Please submit the following items along with your request: <br />✓ A � statement of not less than 500 words describing the significance of the person being honored. <br />The statement should include detailed information about the proposed Honoree summarizing the <br />Honoree's accomplishments, and reasons as to why the person should be publically recognized. <br />✓ A petition of support for the proposed Honorary Sign or Honorary Feature. The petition should be <br />signed by not less than frfty (50) residents of the City of South Bend and must include the name, <br />address, signature and date of signing. The petition should be witnessed by one individual and must be <br />notarized prior to submittal. (Note: All information on the petition must be legible in order to be <br />considered.] <br />Upon submission of this Application, please allow four ( 4) weeks for staff to review, and presentation to the <br />City's Board of Public Works for final action. A letter will be sent to the Applicant indicating the Board's <br />decision. In the event that the Application is denied, the Fee will be refunded to the Applicant. <br />4. SIGNATURE OF APPLICANT <br />My application consists of the following items: (Please check)□ Completed Application Form plus one ( 1) copy □$100.00 Application Fee (Make checks payable to: City of South Bend) □Tyv,,d stateml""'describing the nificance of the person being honored <br />� □Petition of sup <br />1 1,#/�(_2/ Dale <br />Printed Name V2.ll.2021 ck#o27572 <br />XX X <br />