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^ryas, LOCAL AUTHORIZATION FOR TEMPORARY BEER & WINE PERMIT APPLICATION <br />INSTRUCTIONS. 1. A icantmustcom leteailre uested rnf m t n <br />PM P q of a ro <br />2 Please type orpnni clearly <br />j 3. Obaunthe required commundyclearance signatures and upload with the online temporary event application. <br />NOTE'. THIS FORM IS ONLY TO BE USED W 7H ONLINE APPLICATION. Visit Rnps,iimylicensein.goOeGov:PnLI htmlmsubnr:theanlineappvicabon <br />• <br />CJ <br />STEP I. GENERAL INFORMATION <br />Name of applicant applying for permit (organization club, corporation, individual- such as XYZ 123 )nc) <br />MAKE SOUTH BEND LLC for Rebel Art Fest <br />Address of applicant (number and meet city, state, and ZIP code) <br />E-mail address <br />2228 Mishawaka Ave, South Bend, IN 46615 <br />michelle (9 makesouthbend. com <br />Printed name of person making applicationFax <br />number <br />Emergency contact telephone number <br />Michelle FitzGerald <br />) <br />( 574 ) 303a177 <br />Printed name of contact person of event <br />Emergency contact telephone num r <br />Michelle FitzGerald <br />( 574 ) 303-7177 <br />STEP 2. EVENT INFORMATION <br />Beginning day (Monday. Tuesday. etc) <br />Sunday <br />Beginning date (month, day. year) <br />Ending day (Monday, Tuesday. etc) <br />Ending date (month, day, year) <br />June 1, 2025 <br />Sunday <br />June 1, 2025 <br />Time of event � <br />n tim <br />Start 12:00 OM aPM End thine <br />e <br />� <br />nmk <br />8:00 1__ I� <br />Type or description of event <br />Local music and art festival <br />Exact address of event (numberand street, ary, state. and ZIP code) <br />Potawatomi Park, 500 S. Greenlawn Ave, South Bend, IN 46615 <br />STEP 3. FLOORPLAN <br />Q <br />T6 V <br />W ALL S 1-, <br />STEP 4. APPLICANT VERIFICATION <br />The below signed applicant affirms under the Wattles 0/perjury that the information contained in this form is true andaccurate. <br />Signature of applicant <br />Date signed (month, day. year) <br />4/15/2025 <br />STEP S. COMMUNITY CLEARANCE <br />Or�� <br />t pounty, or o i Town Marshall o(jurisdictior where the event will beheld <br />yyyggq da ar <br />!_ <br />2. Signature of the mayor (if the event is held in Fort KaymeW <br />Date signed (month, day. year) <br />