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SIDEWALK CAFE APPLICATION <br />City of South Bend - Board of Public Works <br />227 W. Jefferson Boulevard, Ste. 1316 <br />South Bend, IN 46601 <br />RESTAURANT/BUSINESS INFORMATION: <br />Name of Restaurant/Business: S J %V�-n Eym LU/ <br />Address of Propc <br />Mailing Address: <br />F APPLICANT INFORMATION: <br />Applicant Legal Name. I LQ �Li Phone: 5-79 136- 0sc <br />Title: ❑ Owner Manager ❑ Other <br />Email Address:G'1fG�[,f VS ID <br />i INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />_ J <br />❑ Completed application including $10 fee. Make checks payable to City of South Bend. <br />❑ Site plan depicting the proposed sidewalk cafe showing placement/dimensions. <br />❑ Completed Agreement <br />❑ Certificate of Insurance ($1,000,000/occurrence and $300,000 person naming the City <br />of South Bend 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 <br />South Bend Municipal Code and with all the provisions stated above as conditions of the <br />issuance of this Permit. I further agree to indemnify, defend and hold harmless the City of <br />South Bend from any liability, loss, cost, damage or expenses, including attorney fees, which <br />the City may suffer or incur as the result of any use of the public sidewalks for a sidewalk <br />cafe as permitted herein. I do hereby certify and affirm that all the information given in this <br />application is true to the best of my knowledge. <br />11 <br />Signature of Applicant: i ��` Dater <br />OFFICE USE ONLY - <br />Date Received: Fee Paid: y <br />•� l�U� Approval Date: <br />A �. <br />