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RESIDENT SIQLATURES Page of <br />We have been informed, agree to, and request that the Board of Public Works of the City of <br />South Bend authorize a block party in the area described as: <br />Street Name <br />Date of Event <br />1. / <br />2. <br />3. <br />El <br />4 <br />to <br />Cross Street <br />Name <br />n✓�L4 V'(-41 is�7i <br />Address <br />Gr E, 4 S <br />Phone No. <br />Z 477 <br />Date <br />S (' <br />Signature <br />Name <br />Address <br />Phone No. <br />Date <br />Signature <br />Name <br />Address <br />Phone No. <br />Date <br />0 <br />7. <br />A <br />Signature 9' <br />Name <br />Address <br />Phone No. <br />Date <br />Signature 1 <br />Name <br />Address <br />Phone No. <br />Date <br />Signature <br />Name <br />Address <br />Phone No. <br />Date <br />Signature <br />Name <br />Address <br />Phone No. <br />Date <br />Signature <br />Name <br />Address <br />Phone No. <br />Date <br />Signature <br />Name <br />Address <br />Phone No. <br />Date <br />0. <br />Signature <br />Name <br />Address <br />Phone No, <br />Date <br />Cross Street <br />Updated 4/2013 5 <br />