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APPLICATION <br />THE USE OF, AND BLOCKING OF ACCESS TO THE PUBLI4Px` <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY <br />.i: <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 APPLICAT`I�ON. <br />Applicant Name: e&) �/"ii ` �/�✓/� /%�/'I'JIN <br />Address:"?gq 1 <br />jjj}1 �j6X c. • City: �6• /0 State:..%-1/ Zip y66,4,6 <br />Phone: Cy�q qcq / 3/,Q <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the <br />specified public ri ht-of--way by Applica for the h mg of he `hereinafter described event: (� <br />Event Name ��/�fi�OQC�QD(� �j©Cr(Lty�1�9Y11lJ1�tYti7t'�OC(� i(71Q�4( <br />Street Closure Name of a01L& sJO�, / I <br />Street 1 , <br />From <br />Date of Event �0 <br />Time Setup <br />10 <br />�20 �l <br />Start ICJ NCypf� ❑a.m. ❑ <br />a.m. O� p.m. <br />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 <br />neighborhood. <br />End y ❑a.m. M/pm. <br />Yes ❑ No <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, 41h Floor, County -City Building, <br />227 W. Jefferson Blvd., South Bend, Indiana. <br />[✓� Yes ❑ No <br />[� Y❑ No <br />[� Yeses ❑ No <br />Yes ❑ 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 $4 0. 0st be submitted with application. <br />• Application cannot be processed w JF4�sit. <br />• Deposit will be returned upon insp ctivent area by the Board of Public Works. <br />0 <br />Updated 4/2013 <br />