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I <br />'A <br />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: G <br />Address of Proposed Sidewalk Cafe: <br />Mailing Address: <br />9.3� s R k <br />APPLICANT INFORMATION: <br />Applicant Legal Name: G !S ,� `Z VJC� Phone: <br />Title: Owner ❑Manager ❑Other Far`-T w <br />Email Address: <br />ajy-,- V( <br />J <br />S -� -I - -113 3 - S`t�s- l <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <br />1L 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 />t7 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 />Signature of Applicant:--� Date: <br />OFFICE USE ONLY- 14 � ,o ' 1 <br />Date Receiveed` ;�� Fee Paid: 1 �1` 11 Approval Date: <br />r <br />