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APPLICATION <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY <br />a <br />R <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: F,-t'v n : ` -F y e tth Fuuls6ck}16%-j <br />Address: IQtft M, Fremont City: ``7cu4 h 3e nc- State: T_Q Zip `4 6 tot d <br />Phone: 5"]L1-3`i-1 ,2 ti 31 <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 Names}cpThe- Vioienee 13cstk+oSch6cl31ockPcvrl-N Us <br />Street Closure Nameof <br />Street F-r-e_mo n-i S+, <br />From Y'(�0.Y'CLU�i-FQ. S+, <br />To <br />Date of Event �iLk�LkSt <br />Time Setup <br />eCncy_L <br />14cLmiI�ov� SI <br />2-00" 20 L(� <br />a Start <br />a.m. <br />Approximate Number of <br />Attendees <br />Please answer the following appropriately: <br />❑a.m. ® End <br />p.m. <br />• This event will be open to residents outside the immediate <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 />❑a.m. ❑p.m. <br />6pri 3,,:,�, <br />D'0�� <br />M Yes ❑ No <br />Yes ❑ No <br />® <br />Yes <br />❑ <br />No <br />[� <br />Yes <br />❑ <br />No <br />❑ <br />Yes <br />❑ <br />No <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 wil be returned upon inspection of event area by the. Board of Public Works. <br />X <br />r`'�i_� g i_7`ji <br />Updated 4/2013 AN Gram\ <br />