Honorary Street Sign - Dave (Dutch) Koehler Blvd.

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PLACEMENT OF HONORARY SIGN WITHIN THE PUBLIC RIGHT-OF- WAY OR ON PUBLIC PROPERTY APPLICATION City of South Bend — Board of Public Works For Office Use Only: ❑ Application Complete 227 W. Jefferson Boulevard, Ste. 1316, ❑ Fee Received South Bend, IN 46601 ❑ Petition Complete APPLICATION INFORMATION Applicant's Name: AJC 4,41- MA4145 Applicant's Address: �JbZ 5 `�'LG 2. S Email Address: 4p-i^ jg%c 3) Coo Telephone/Cell: 63•4-3y67/ '�b 1 Honorary Sign Request: Honorary Sign Request Name (sign should read): � A✓W 1N rr<-L I4,45,6 a[ LE 2 Blvd. (St., Blvd., Ln., Etc) Is this individual deceased? tC Yes _ No (if no, individual is not eligible for honorary sign.) If the Board approves the petition, the petitioner must pay two hundred and 00/100 ($200) per sign to be manufactured and installed by City employees. The City will neither approve or install more than four (4) Honorary Street Signs per Honoree. CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS Proposed Location(s): Location #1: Intersection of d ISVE & L yv 00Ar 4 Location #2: Intersection of & Location #3: Intersection of & Location #4: Intersection of & (Example: Intersection of North 8 South Street) vj�a Elizabeth A. Maradik, President 6f ile-t Gary A. Oiler, Member Murray L. Miller, Member Joseph R. Molnar, Vice President Jordan V. Gathers, Member Attest: Theresa M. Heffner, Clerk Date: Jtme 27, 2023 Did the individual live in South Bend? X Yes _ No (if no, individual is not eligible for honorary sign.) Significance of Location to Honoree's Life: SFE yF Ljf 'Cv ThG C,!;-ry off' sy uT--k b "6, j p,.tb _T + S C%T� z 014 S Fc> rz oe 5 REQUIRED SUBMITTALS Please include the following items along with your request: ✓ A statement of not less than 500 words describing the significance of the person being honored. The statement should include detailed information about the proposed Honoree summarizing the Honoree's accomplishments, connection to South Bend, Indiana, and reasons as to why the person should be publicly recognized. ✓ A petition or support for the proposed Honorary Sign. The petition should be signed by not less than 200 residents of the City of South Bend and must include the name, address, age, signature, and date of signing. [Note: All information on the petition must be legible in order to be considered.] Upon submission of the Application, please allow eight (8) weeks for staff to review, and presentation to the City's Board of Public Works for final action. A letter will be sent to the applicant indicating the Board's decision. In the event that the Application is denied, the Fee will be refunded to the Applicant. SIGNATURE OF APPLICANT My aXlication consists of the following items: (please check) LK Completed Application Form � $150 Application Fee (Make checks payable to: City of South Bend) Fee goes toward the price of the sign(s) B /Typed statement describing the significance of the person being honored as described above C' Petition of support 4440�yx- V k N4 &J M.4 Z A 5 os - I S= 7-3 Signature Printed Name Date