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SIDEWALK CAFE APPLICATION <br />City of South Bend - Board of Public Works <br />227 W. Jefferson Boulevard, Ste. 1316 <br />+5 South Bend, IN 46601 <br />RESTAURANTBU51 NE55 INFORMATION: <br />Name of Restaurant/Business: R.M c_ Cd2 2 <br />Address of Proposed Sidewalk Cafe: 1 z H +'l 1 :S L S� �- ��� Z 1j q' I <br />Mailing Address: Dazes -2. <br />APPLICANT INFORMATION: <br />Applicant Legal Name: Y-7 _ Phone: 5 -,,7 q � 2 8 '; . s-7 Z L/ <br />Title: ❑ Owner PSI Manager ❑ Other <br />Email Address: bL1,J-0koa r-'r-� <br />INCLUDE THE FOLLOWING ITEMS WITH YOUR APPLICATION: <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 knowl e. <br />Signature of Applicant. Date: 2� <br />J <br />OFFICE USE ONLY: ! ��� <br />Date Received: Fee Paid: Approval Date: <br />