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- �yplJ Tll gF,p <br />APPLICATION <br />THE USE OF, AND BLOCKING OF, ACCESS TO THE PUBLICS 2 <br />0 <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY PEACE <br />The Board of Public Works must have four (4) weeksgprrior, got* of the event. „ 1865 <br />A NON-REFUNDABLE APPLICATION FEE OF $50.04-IN THE FO t A CERTIFIED <br />CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE <br />INCLUDED WITH APPLICATION. <br />Applicant Name: L /} QC cs,t (UN <br />Address: d . r v K- y,,-y>— City: S State: Zip tf 1' 3 <br />Phone: S7 `i - 3 3 7 -,4 -7,,1 <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 L i p t )4, w' <br />Street Closure Name of <br />Street <br />From J FcCI, <br />To `- � ( C- <br />Date of Event - 0 6 20 <br />Time Setup ' Start 1&, oo Wa.m. ❑ End <br />(p ; c9a ❑a.m. 25p.m. <br />a.m. p.m. <br />p.m. <br />Approximate Number of <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to re«;dents outside the immediate <br />Yes ❑ No <br />neighborhood. <br />• All residents on the affected block have been notified and invited. A <br />❑ Yes ❑ No <br />copy of the flyer distributed is included. <br />• This event will have music (live or other). <br />�{ <br />Yes ❑ No <br />• Payment of $50.00 fee payable to City of South Bend included or: <br />❑ Yes ❑ No <br />• For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal <br />❑ Yes No <br />Revenue Exemption Status Document and a current copy of Form 990 <br />of Form 990-EZ are included with this application, and additionally filed <br />with the Office of the City Clerk, 4"' Floor, County -City Building, 227 <br />W. Jefferson Blvd., South Bend, Indiana. <br />IF ALCOHOL IS TO BE SERVED 035OLD <br />Alcoholic beverages will be served ❑ Alc c beverages will be sold ❑ <br />Certified Check or Money Order fol .'400.00 must ubmitted with application. ❑ <br />• Application cannot be processed without osit. <br />• Deposit will be returned upon insp on of event area by the Board of Public Works. <br />�/� <br />Updated 4/2013 <br />1 <br />