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Name: <br />Gi6oyae7-4,6tr &Iddl�y 11V( <br />Title: <br />BOARDD OF <br />PUBLIC WORKS APPROVAL <br />President Member Member <br />Q& wi�� <br />Member <br />DATE <br />4MVr27:-� <br />Date <br />APPLICATION FOR SIDEWALK CAFt PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />FEE PAID <br />Applicant's Legal Name Title <br />� �kr y� L r0�lti° A�iCe B�1d�Py �yG <br />Business Name <br />Address <br />Telephone Number <br />Proposed Location and Description of Sidewalk Cafe /,q/ <br />Q e f Tgl/Rgi 1r <br />4/ <br />Days of Sidewalk Cafe Operation <br />Hours of Sidewalk Cafe Operation <br />Sun <br />Mon <br />Tues <br />Wed <br />Thurs <br />Fri <br />Sat <br />The following information is REQUIRED for completion of a Sidewalk Cafe Application: <br />I. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafe showing placement/dimensions of proposed cafe <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend <br />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 South Bend Municipal <br />Code and with all the provisions stated above as conditions of the issuance of this Permit. I further agree to <br />indemnify, defend and hold harmless the City of South Bend from any liability, loss, cost, damage or expenses, <br />including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a <br />sidewalk cafe as permitted herein. I do hereby certify and affirm that all the information given in this application is <br />true to the best of my knowledge. <br />4 <br />