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APPLICATION FOR USE OF - `-
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PUBLIC RIGHT-OF-WAY FOR EVENT
The following special event has been approved by the Special Events Committee. +a+s
Submitted by: Denise Miller
Event name: Clark Birthda
Event Date: July 4 2023
Street Closure: Haney St between Fellows/Carroll St
Closure Times: 3:00 pm to 9:00 pm
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
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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
j' $25 application fee if filed 30 days or greater (up to 180 days) in advance of event.
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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 - Aoplicant Information
Date of Application: D Organization Name:
Applicant(Contact)Name: O/' 15
Applicant (Contact)Phone:.Uy jSz [- 10 Contact Email: dlowcL-4^r— io95otna L,Coni
Address: Y%1 � • l-l-A-NevAve-, City/State/ZIP:Sn).j4'I, (P-ti01, ZN
Secondary Contact Name:
Contact Phone:51 V 300 - 37 S� Contact Email:
Address: ND 2 F. / &4? City/State/ZIP: `5nol ►,r SE-)y oL Ilu V&g1-3
Section B -Event Information
Event Name: P)iC4—h d6: �I fir } ��o Expected Attendance:
Requested Street
From (Cross Street): Fe'ell a 1j!5=1: , (ZIPVr r�ei1 L ST
To(CrossStreet): `rV &P"r-f--e-'I ST
Provide a brief description of the event:
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Date of Event Setup [mm/dd/yy1:*g `� /- 3 Time: • O p✓✓t
Begin Date of Event [mm/dd/yy]: -7 -/-��_Time: '2) , 00 �Y►�
End Date of Event [mm/dd/yy]: ) - (./ r Time: Q - Do D rvi
Event Cleanup Completion[mm/dd/yy]: Time: S i �f7r- is OOP
Have all residents on the affected block have been notified and invited? Wes ❑ 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:
Will this event have music (live or o e ? 113 yes 0 No
Section C - Alcohol
Will alcohol be served or sold? ❑ Yes WIN o
• If Yes:
o The applicant must apply for and receive a temporary liquor license from the Alcohol &Tobacco
Commission.
c 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:
o Fencing around serving area
o Trash receptacles
o 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
Contact Phone:
M.
• (b) Independent Security Information
Name:
Qualifications:
Name:
Qualifications:
0
Contact Name:
Email:
City/State/ZIP:
Contact Phone:
Contact Phone:
Contact Phone:
Will your event have food sales (food vendors, caterers, food trucks, etc.)? ❑ Yes &1 o
o If yes, the event coordinator must apply for and receive a St Joseph County Health Department
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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.orp/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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Section E - Indemnity & Hold Harmless Agreement
City of South Bend Special Events Committee
• Indemnity & Hold Harmless Agreement
Date: MA%4 2� j _3 Event Date:
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Event Name: �F) I
Organization:
Applicant (Contact) Name:�L/ 1
Applicant (Contact) Phone: Alt. Phone:-® 57Y-f.00 -395 8
Email:
Address: liv.P _ City/State/ZIP: 4�nPJE�un
Event Location (Please describe):
Length of Event (Dates/Times):
• APPLICANT agrees to indemnify, defend and hold harmless the Civil City of South Bend, Indiana, 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.
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Signed on this Date: e y�� I O
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Authorized Organizer Signature
I e.loris M. 0-�L-4rr-
Printed Name and Title
Section F - Permit & Agreement
1. Pursuant to Local Ordinance No. 10628-18,there isa$25.00non-refundable fee for applications filed 30
days or greater in advance of the event date. Applications filed less than 30 days in advance of the event
• date will not be accepted.
2. All residents within the affected area must be notified of this event. The APPLICANT must obtain
signatures from at least 10 residents that reside along the closed right-of-way and make an attempt to
notify all other affected residents. APPLICANTS must include a copy of a brochure or letter of invitation
distributed to all affected neighbors describing the event purpose, date, and time.
3. The APPLICANT is responsible, prior to the event, for determining if there are any affected residents that
need assistance accessing their residence. The APPLICANT is responsible for providing said resident(s)
access or transportation to their property.
4. The cones will be delivered to the APPLICANT's address. The APPLICANT assumes full responsibility for
clean-up and assures the City that all cones will be maintained and returned undamaged. The APPLICANT
will be liable for the replacement cost of $50.00 per cone as a result of any missing or damaged cones.
S. Block parties must end by 8:00 p.m.
6. A street will be blocked off from intersection to intersection only. No half -blocks or alleys can be blocked
Off.
7. The Special Events Committee reserves the right to deny any block party application based on traffic and
speed limit records. No street may be closed with a speed limit over 30 MPH or considered to be a major
arterial.
8. The Special Events Committee reserves the right to deny any block party application based on information
gathered from the South Bend Police Department or other sources.
9. The APPLICANT agrees to allow residents that live on the above -referenced block access in and out of the
restricted area as needed.
• 10. The APPLICANT agrees to abide by all terms and conditions of the South Bend Municipal Code and Board
of Public Works' policy adopted in Resolution No. 10628-18 on December, 11, 2018.
11. Notification of approval/denial of this request will be issued by return of this form, upon signed
authorization by the Board of Public Works.
12. 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 stereos, speakers, musical
instruments, 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).
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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: M TT Y- :�/ zC25 i
Applicant Signature:
Printed Name: U-�— I CJ P I !:—, M , a�
President
Member
SPECIAL EVENTS COMMITTEE APPROVAL
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Member
Date
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CITY OF SB SPECIAL EVE
7315 LAFAYETTE BLVD
SOUTH BEND, IN 46601
OS/31/2023 14:31:31
MID: >D;Xk)DD(XkW401 TID: xxxxx800
DEBIT CARD
DEBIT SALE
Card a
X%XXAXXp W3639
Network:
VISA
Chp Card:
US DEBIT
AID:
A000000098o%e
ATC:
0167
ARQC:
9BF24254C421589F
SEQ #:
3
Bath;:
54
INVOICE
4
Approval Code:
933518
Entry l*OW:
Contactim
Mode:
Iuuar - PIN Verft
SALE AMOUNT �5,00
SOW Not Required
VISA CARDHOLDER
MERCHANT COPY
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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: %�
from to
Street NAme Cross Street C/ N/
Cross Street
Date of Event:
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Signature
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Signature
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Phone No.
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Date
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