Laserfiche WebLink
0450U TH gory <br />APPLICATION z <br />FOR USE OF, AND BLOCKING OF ACCESS TO THE PUBLIC w MCH <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES " a� <br />1865 <br />The Board of Public Works must have FOUR (4) weeks prior notice of the event. <br />A NON-REFUNDABLE APPLICATION FEE OF $125.00, 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 />❑ Fee Paid <br />Applicant Name: Jonathan <br />Address: 2203 Basin St. City: South Bend State: IN Zip: 46614 <br />Phone: (574)707-5345 <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 Urban Adventure Games <br />Location <br />downtown South Ben <br />Street Closure Name of Street S. Lafayette Blvd. <br />Notre Da <br />(Describe <br />and Downtown Mishawaka. <br />From W. Monroe St. <br />To W. Western Ave. <br />Date of Event Saturday, July 30th 20 16 <br />® a.m. ® a.m. <br />Time: Registration/Setup 7:30 ❑ p.m. Start 8:00 El P.M. <br />, ❑ a.m. <br />End 00 Xp.m. <br />Approximate Number of Attendees 1,200 <br />Answer the following appropriately: <br />1. This event will have music (live or other). <br />® Yes ❑ No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />® Yes ❑ No <br />2. Required Information to Accompany Application <br />a. Certified Check or Money Order in the Amount of $125.00, or: <br />b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) <br />Internal Revenue Exemption Status Document and a current copy of <br />Form 990 of Form 990-EZ are included with this application, and <br />❑ Yes ❑ No <br />additionally filed with the Office of the City Clerk, 41h Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />c. Certificate of Insurance <br />d. Maps, drawings of the area and setup plan <br />❑ Yes ❑ No <br />k�' <br />a. This event involves City streets <br />® <br />Yes <br />❑ <br />No <br />b. This event involves County roads <br />❑ <br />Yes <br />❑ <br />No <br />c. This event involves State highways <br />❑ <br />Yes <br />® <br />No <br />d. This event involves the use of the sidewalk <br />❑ <br />Yes <br />❑ <br />No <br />Updated 4/2015 1 <br />