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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: I na <br />Address of Proposed Sidewalk Cafe: 1t\ �� a' z u e �i� L�24► 6 �V� L�(CuL\ <br />Mailing Address:\ �� ��,i�l S!0-da Si_ L%, Zi- 6 1� LULCA <br />. APPLICANT INFORMATION: <br />Applicant Legal Name: <br />Title: ❑ Ownei <br />Email Address: <br />Phone: ,(�7q- 3LIq - 5q0 5 <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />L L'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 />CAP <br />C ,1Certificate of Insurance ($1,000,000/occurrence and $300,000 person �r�atpin t 5 <br />nCi <br />of South Bend as additional insured) Div. o$ Et+,,ug <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 />Signature of Applicant: , Date: <br />OFFICE USE ONLY: <br />Date Received: Fee Paid: Approval Date: <br />