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• City of South Bend Special Events Committee <br />Indemnity & Hold Harmless Agreement <br />Date: /)3 Z.-� Event Date: kiIgQ /?q <br />Event Name: beSvisi t- Cx'nSi re-�i%jcl <br />Organization:) �(n ri d-Cn <br />Applicant (Contact) Name: - <br />Applicant (Contact) Phone: GJ 7'I ' 3 I I f, I Alt. Phone: <br />Address: C�Io of p asn FmV(1 ,u <br />Event Location (Please describe): <br />4U.6 • <br />Length of Event (Dateslrimes): <br />UAn ty Ge4,vps Moy-,� P-cs} Blvd <br />d;x y {ard rnckeD <br />Insurance Amount: This event is insured for no less than $700,000 per occurrence and $1,000,000 in aggregate, <br />• and the certificate of insurance includes a rider naming City of South Bend, Special Events Committee, and Board <br />of Public Works as additionally insured for the event. <br />Organization Name: l J fU t V 9 C1 CT(1tS l r\r • agrees to indemnify, defend <br />and hold harmless the Civil City of South Bend, Indiana, from any liability, loss, costs, damages or expenses, <br />including attorney fees, which the Civil City of South Bend, Indiana, may suffer or incur as a result of any claims <br />or actions which may be made against the City, its agents, employees, or subdivisions by any person, including a <br />participant in the activity, arising out of the approval of this request by the Civil City of South Bend, Indiana, <br />through the Board of Public Works, to close a portion of the public right-of-way for the event described above, <br />or for any harm or damage alleged to have occurred because of the holding of the special event The <br />undersigned certifies that he/she is authorized to bind the APPLICANT to these terms. <br />Signed on thioDate: LL (`� 2Q <br />Authorized Organizer Signature <br />&" StCA')"Ou <br />0 Printed Name and Title <br />FJX op-A6 Vv 1 t <veJc( - 1J l l l V l ab-(,) S I ae , <br />