HomeMy WebLinkAboutSpecial Event - 4th of July Fireworks - July 4FSDI TN @F
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APPLICATION FOR USE OF
PUBLIC RIGHT-OF-WAY FOR EVENT
The following special event has been approved by the Special Events Committee. 1965
Submitted by: Denise Miller
Event name: 4th of July Fireworks
Event Date: July 4 2023
Street CIosure: Allen St between Lindsey/Allen
Closure Times: 7:30 pm to 12:00 am
Sidewalk Closure: ❑ Yes ❑■ No
Comments: Neighbors gather to enjoy the 4th of July
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
Elizabeth A. Maradik, President
Gary A. Gilot, Member
Murray L. Miller, Member
Joseph R. Molnar, Vice President
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Jordan V. Gathers, Member
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Attest: Theresa M. Heffner, Clerk
Date: June 13, 2023
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City of South Bend Special Event Application
Neighborhood Event
t ?' $25 application fee if filed 30 days or greater (up to 180 days) in advance of event.
Please Brine Completed Application and Payment to:
Public Works Service Center, 731 S. Lafayette Blvd., South Bend, IN
Review the Instructions on the Special Events page before completing the application. Neighborhood Special
Event applications must be submitted more than 30 days in advance of the event date or the application will not
be accepted.
Section A - Applicant Information
Date of Application: S- i Ll - X Organization Name: V/P
Applicant (Contact) Name: /'0 c N�/ d Y R O� e/ I �5
Applicant (Contact) Phone: P "2q);-sa- 6 o a 6 Contact Email: n 0 rs+
Address: 7 o q A I Le N ST City/State/ZIP: SatiT /4 Be- N/l -I- N yb 1v�6
Secondary Contact Name:
Contact Phone:
Email:
Address: City/State/ZIP:
11 _ Section B - Event Information
Event Name: jrl I�I U F ill I Y rl' IZ < W oj� Kixpected Attendance:
Requested Street
From (Cross Street):
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To (Cross Street):
y A P%
8 of Q-e to
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A r D A 5 T
Provide a brief description of the event:
'-ITH OF JL4I y F, rye voRf< SN ow
Fo� I`H�fiat P?OHboRHood
Date of Event Setup [mm/dd/yy]: '2 Time:
Begin Date of Event [mm/dd/yy]: 7 / _ °2 Time:
)t30?/Y7
7 . S o 1-0
End Date of Event[mm/dd/yy]: 7 - L1 '-,)- 3 Time: 1 dC' 60 AP)
Event Cleanup Completion [mm/dd/yy]: 7 - L/ - c)- 3 Time: / A// /n
Have all residents on the affected block have been notified and invited? [ 4es ❑ No
Please attach a copy of the door hanger or letter used to notify residents in addition to signature attachment.
Number of households fronting the proposed street closure:
Number of households represented by signatures on attached sheet: O
Will this event have music (live or other)? El Yes L`'f No
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Section C - Alcohol
Will alcohol be served or sold? ❑ Yes O'No
If Yes:
o The applicant mustapplyfor and receive atemporary liquor licensefrom theAlcohol &Tobacco
Commission.
o Application cannot be processed without a copy of this license.
o A refundable $400.00 deposit paid by card or check (made to City of South Bend) must be submitted
with application.
o Application cannot be processed without deposit.
o Deposit will be returned upon inspection of event area by the Board of Public Works.
o The applicant must submit a map or drawing of:
Fencing around serving area
o Trash receptacles
c Events that will have alcohol sales must provide security. If your event will be hiring a security company,
please provide its contact information in sub -section (a) below. Otherwise, please list the names, phone
numbers, and qualifications (e.g. Off -duty police officer, professional security guard, or event applicant)
of three (3) security guards in the fields provided in sub -section (b).
(a) Security Company Information
Company Name: Contact Name:
Contact Phone:
Email:
Address: City/State/ZIP:
(b) Independent Security Information
Name:
Contact Phone:
Name: Contact Phone:
Qualifications:
Qualifications:
Contact Phone:
Section D - Food ,,�
Will your event have food sales (food vendors, caterers, food trucks, etc.)? ❑ Yes ly No
• o If yes, the event coordinator must apply for and receive a St Joseph County Health Department
Temporary Event Permit.
o Vendor(s) must also apply for and receive a St. Joseph County Health permit. Health Permits must be
filed with the county 30 days prior to the proposed event. Each vendor must obtain necessary permits to
serve on -site and display these permits at the event.
o All applications and guidelines can be found on the St. Joseph County Health Department Food Service
website at sichd.ore/food-service.
Please select food types: ❑ Food Vendor ❑ Caterer ❑ Food Truck ❑ Other:
If a Food Truck, please list company name(s):
Please describe how food will be cooked and served:
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City of South Bend Special Events Committee
• Indemnity & Hold Harmless Agreement
Date: ' - I W _ �' � Event Date: 7- y- of 3
Event Name: LI T 14 O r f`11 Y r i g e W o R k S
Organization: N /
Applicant (Contact) Name: o 6 /y ig 01 go me I I N 5
Applicant (Contact) Phone: (S-% -V) S z ' C 0.- 6 Alt. Phone:
Email ON A I d4T 7 /4 R ' e 0�
Address: � U� fi I e N i 7 City/State/ZIP: So 07 H D -ee j.
Event Location (Please describe):
0F����e1
Length of Event (Dates/Times)
7_Ll-�3To7-1-/-23 8PMTOI,Z190
• APPLICANT agrees to indemnify, defend and hold harmless the Civil City of South Bend, I ndiana, from any
liability, loss, costs, damages or expenses, including attorney fees, which the Civil City of South Bend, may suffer
or incur as a result of any claims or actions which may be made against the City, its agents, employees, or
subdivisions by any person, including a participant in the activity, arising out of the approval of this request by
the Civil City of South Bend, Indiana, through the Board of Public Works, to close a portion of the public right-of-
way for the event described above, or for any harm or damage alleged to have occurred because of the holding
of the special event. The undersigned certifies that he/she is authorized to bind the APPLICANT to these terms.
Signed on this Date: S � 3o , � 3
A o.,A 7w.,
Authorized Organizer Signature
�QyJ�I <) td
Printed Name and Title
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I have read the Application and the Permit and Agreement for this Special Event and I affirm the truth of
the information provided by me to the best of my knowledge. I understand and agree to the above rules
and regulations, and any applicable state and federal laws. I also understand that this application may be
denied based on any false or incomplete information.
Date: <— ,� 9 — 9,3
Applicant Signature:
Printed Name: U O N A I d 6 9 0 rn e i I N 9
SPECIAL EVENTS COMMITTEE APPROVAL
President
► 1 Member
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Member
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Date
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Neighbor Signature Sheet - Neighborhood Special Event
We have been informed, agree to, and request that the Special Events Committee of the City of South Bend authorize a
block party in the area described as:
IZIV 5I from NDSeiS to V19P Y KCt-3T
Street Name Cross Street Cross Street
Date of Event: 7 tj —,Z3
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Signature
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Name
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Address
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Phone No.
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Phone No.
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Date
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Signature
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Phone No.
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Google Maps
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Lindsey St & Allen St
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Faith Deliverance Center < i0
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QKingdom Life
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Elizabeth Memo6 ieh ' •
Church of God in Christer A a
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g Lindsey St
Greater Mount
2 Calvary MB Church
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Cozy. Bohemian,
Free Eggs
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Birthday Chair
Van Buren St 0 Van Buren St
x Peters Rock Missionary
I Baptist Church
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Tony's Kitchen U Google
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Raising Augels Daycare
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