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SoUrH APPLICATION FOR THE USE OF, AND BLOCKING OF ACCESS TO THE PUBI, . (^ \� RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY Wi PeAC The Board of Public Works must have four (4) weeks prior notice of the event: I8e5 A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDEJ) WITH APPLICATION. Applicant Name: Address:3L)y 5-suvtn4Sk8'-City: dt � r�e� State: y 13 Zip (-4Wi S Phone: 5gLy - 3-\S This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name OAne sk B IoC k Pay tj Street Closure Name of Street V V 1-ZA�kl k From �_,� To Date of Event �J 1 20 1 Time Setup 3 : oor rn ❑ Start .41: C 0- ❑a.m. ❑ End �.C�O ❑a.m. Eg". a.m. L,p m. p.m. Approximate Number of Attendees Please answer the following appropriately: • This event will be open to residents outside the immediate neighborhood. • All residents on the affected block have been notified and invited. A copy of the flyer distributed is included. • This event will have music (live or other). • Payment of $50.00 fee payable to City of South Bend included or: ❑ Yes R, No ©Yes ❑ No ©Yes Yes • For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal ❑ Yes Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are included with this application, and additionally filed with the Office of the City Clerk, 4t' Floor, County -City Building, 227 W. Jefferson Blvd., South Bend, Indiana. IF ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ Certified Check or Money Order for $400.00 must be submitted with application. • Application cannot be processed without deposit. • Deposit will be returned upon inspection of event area by the Board of Public Works, 1 No No No FOR Updated 4/2013