HomeMy WebLinkAboutStreet Closure - Flora Coley
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APPLICATION
RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY`PRACE
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The Board of Public Works must have four (4) weeks prior notice of the
A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED
CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE
INCLUDED WITH APPLICATION.
Applicant Name: t-IOYZ �. k�
Address: N- 6rMr-6e�City: S-ac(+` C"C' State: JK Zip quLOA
Phone: 5_7q-.S-1q- U
This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the
specified public right-of-way by Applicant for the holding of the hereinafter described event:
Event Name
Street Closure Name ofl—��
Street
From Ke k tt c
Date of Event `7 - L _ I _� 20 t1
Time Setup cc P1 Start q ,`bz) 12a•m• ❑ End
(B;OD ❑a.m. Fdp.m.
a.m. p.m.
El
p.m.
Approximate Number of
Attendees
Please answer the following appropriately:
• This event will be open to residents outside the immediate
KA Yes ❑ No
neighborhood.
• All residents on the affected block have been notified and invited. A
Yes ❑ No
copy of the flyer distributed is included.
• This event will have music (live or other).
[7 Yes ❑ No
• Payment of $50.00 fee payable to City of South Bend included or:
[A Yes ❑ No
• For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal
❑ Yes ❑ No
Revenue Exemption Status Document and a current copy of Form 990
of Form 990-EZ are included with this application, and additionally
filed with the Office of the City Clerk, 4`t' Floor, County -City Building,
227 W. Jefferson Blvd., South Bend, Indiana.
IF ALCOHOL IS TO BE SERVED OR SOLD
Alcoholic beverages will be served n Alcoholic beverages
will be sold ❑
Certified Check or Money Order for $400.00 must be submitted with application. ❑
• Application cannot be processed without deposit.
• Deposit will be returned upon inspection of event area by the Board of Public Works.
Updated 4/2013 1
Names and phone numbers of THREE security guards
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• To monitor underage drinking.
• Qualifications must be listed (e.g. Off -duty police officer, professional security guard, or event
APPLICANT).
A drawing must be submitted showing: ❑
• Fencing around serving area
• Trash receptacles.
o Ample trash receptacles must be provided to ensure proper disposal of refuse.
Temporary liquor license. ❑
• Call the Alcohol & Tobacco Commission at (317) 234-4315 for more information.
• Application cannot be processed without a copy of this license.
13. The City of South Bend Noise Ordinance is in effect at all hours. Between the hours of 11:00
p.m. and 7:00 a.m, certain noises are particularly prohibited. These include operating radio
receiving sets, musical instruments, phonographs and other sound reproduction devices if
audible fifty (50) feet away, as well as shouting, yelling, hooting, whistling, or singing in the
streets in a manner to disturb the peace (Municipal Code 13-57).
I have read the Application and Permit and the Agreement for the "Use of Right -of -Way for Block Parties"
and I understand and agree to the above rules and regulations. I also understand that this application may be
denied based on any false or incomplete information.
Dated this day of ��u n e 20 1-7
APPLICANT Signature VL
Printed Name
BOARD OF PUBLIC WORKS APPROVAL
a
President
Me ber Member
Member
Member Date
RETURN FORM TO:
Board of Public Works
1316 County -City Building
227 West Jefferson Boulevard
6/---1 7['10 r
South Bend, IN 46601
Phone: (574) 235-9251 i Fax: (574) 235-9171 • E-Mail: publicwlcs@southbendin.gov
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RESIDENT SIGNATURES Page of
We have been inforined, agree to, and request that the Board of Public Works of the City of
South Bend authorize a block party
%in the area described as:
from (1 �! ��"� _ to (/t
Street Name Cross Street Coss Street
Date of Event
1.
Signature
Name
Address
Phone No.
Date
2.
Signature
Name
Address
3.
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Phone No. y13 ` (P
Date
Signature
Name
Address
Phone No.
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.7.
Date
4.
Signature
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Name
M/�
Address
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Phone No.
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Date C
5.
Signature
10.
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Name
OPri iVACe—,
Address
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Phone No.
�7q 90,3 -L l
Date
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Signature a U try ( Q(
Name 6_61- CO ke-
AddressS-
Phone No.j�L(
Date
Signature
Name rQ
Address }
Phone No.
Date ((J b y l
Signature
Name dC�
Address
Phone No.
Date
Signaturecl�a
G
Name
Address
PhoneNo.
Date
Signature 1.
Name
Address
Phone No.
Date 1— ::L "- ,
Updated 4/2013 5