Laserfiche WebLink
�4,011TA4- <br />APPLICATION o <br />FOR THE USE OF, AND BLOCKING OF, ACCESS TO THE PUBLICS , 2 <br />0 <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY m Pa u <br />y <br />The Board of Public Works must have four (4) weeks prior notice of the event. 1865 <br />A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED <br />CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE <br />INCLUDED WITH APPLICATION. <br />Applicant Name:S �`, p�jU� 0*47) 1pf'sl 6 "oob <br />Address: Lj�h I'soy`" S �' City: s 04A 04 State: —,7,r Zip <br />Phone:; j' {+ 7 a - G t �7 <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the <br />specified public right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name S`) Pau p i n��1 �� i an mi Y ✓ i <br />Street Closure Name of ^ ^CAW' <br />Street ' v l✓ _ _ 1 <br />From Jcvvj/JJ j� <br />To <br />Date ofEventjq)y �-3 20 �� �� <br />Time Setup �i 0' Start I (� • (�d E a m. ❑ End I r v(f ❑a.m. Mp.m. <br />�O f f'o � a_rr p.m. <br />a' 60 f.— p.m. <br />Approximate Number of <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate 62/ Yes ❑ No <br />neighborhood. <br />• All residents on the affected block have been notified and invited. A <br />copy of the flyer distributed is included. <br />• This event will have music (live or other). <br />• Payment of $50.00 fee payable to City of South Bend included or: - <br />For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal <br />Revenue Exemption Status Document and a current copy of Form 990 <br />of Form 990-EZ are included with this application, and additionally <br />filed with the Office of the City Clerk, 4a' Floor, County -City Building, <br />227 W. Jefferson Blvd., South Bend, Indiana. <br />N) Yes ❑ No <br />Yes <br />Yes <br />Yes <br />IF ALCOHOL IS TO BE SERVED OR SOLD <br />Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ <br />Certified Check or Money Order for $400.00 must be submitted with application. <br />• Application cannot be processed without deposit. <br />• Deposit will be returned upon inspection of event area by the Board of Public Works. <br />❑^/ No <br />LV No <br />❑ No <br />Updated 4/2013 <br />