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APPLICATION FOR USE OF z
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PUBLIC RIGHT-OF-WAY FOR EVENT ,}
The following special event has been approved by the Special Events Committee. is6s
Submitted by: Denise Miller
Event name: Annual Halloween
Event Date: October 27 2024
Street Closure: Manitou Place between Forest/Park
Closure Times: 2:30 pm to 5:30 pm -
Sidewalk Closure: ❑ Yes ❑■ No
Comments: Event to be held in Park Forest alley entrance to include potluck
food, pinatas, candy search, and hay toss.
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
Elizabeth A. Maradik, President
Gary A. Gilot, Member
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Murray L. Miller, Member
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Joseph R. Molnar, Vice President
Briana Micou, Member
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Attest: Theresa M. Heffner, Clerk
Date: October 22, 2024
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Please Brine Comoleted 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 - Apolicant Information
Date of Application: 9//9/iCP2y
Organization Name: G'J.es/orn
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Applicant(Contact)Name:
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Applicant (Contact) Phone:
ContactEmail:
Address: a•ti Foecs,F
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City/State/ZIP: Sov" Qend
/n/ CY44
Secondary Contact Name:
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Contact Phone: 57 v —so
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Y Contact Email: 6oa i 4 y o 5
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Address:
Section B - Event Information
Event Name: IgAek./w/ }'ia//owcen J—ExpecteclAttendance: liy
Requested Street Closure: AA n e f-o J ;PJ a c t.
From (Cross Street), F✓«+ +0 Pe f K-
To (Cross Street): or 6 4"a I( sn 1.1 .y e e a( .fp w Ze 74ron• Pa.A k 4- +ike-
a~ k. I F•' • s r a 11 cy t n %rM c G C 7A .5 a aLwCis,Pr e•b
Provide a brief description of the event: 6:01 tr cjo L/ c// a. L/I Amp'y ajlv�/• J-f:4 Jl�we� POA4-Lf.Z Men .foJ
P/n•ias, J.ay }esf CA,%a(y sd4Ae4, hatdeps eae•
7}s13 eve..4- Ao f It en a onotw eJ.1 n e aA'7 '"CAI yeaH {ei
`0 yeas.
Date of Event Setup [mm/dd/yy]: /O/ Z*/ Z-V ZY Time: .Z O P W%
Begin Date of Event (mm/dd/yy]: /o�/ ZO Z If Time: 3 : o o
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End Date of Event [mm/dd/yy]: 141 _/ Z O Z i Time: S : u m
Event Cleanup Completion [mm/dd/yy]: /V j Z ffT Time:, *rj —A r"
Have all residents on the affected block have been notified and invited? )SYes ❑ 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 other)? ❑ Yes §9 No
C 1
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Section C - Alcohol
Will alcohol be served or sold? ❑ Yes A No
If Yes:
o The applicant must apply for and receive a temporary liquor license f rom the Alcohol & 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:
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:
Contact
Address: City/State/ZIP:
(b) Independent Security Information
Name:
Qualifications.
Name:
Qualifications:
Name:
Qualifications:
is
Contact Phone:
Contact Phone:
Contact Phone:
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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
webslte at ti j� I i(Lo r-' �1l`.rV lr i.
• 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:
$80R A- 1 d•if 4- o fl%v psi- /. c_&
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City of South Bend Special Events Committee
Indemnity & Hold Harmless Agreement
Date: f Z02-cl Event Date: / C) f / 20 Z y
Event Name: Gh401A Poe/4 n 4A!SIA 641-ADO d A?ce flo deen
Organization: Ci�e�O ' ^ / (7a�.t Ic /U a 1 S 1% 6 • e l.o o d
Applicant (Contact) Name: .! 0 4 n .D n. j nS
Applicant (Contact) Phone: 3 ff 3 ' to 3 `1 V Alt. Phone:
Email: 1 ezr.Am,,b&5 %•( / 91. C.e'yt
• Address: Sc 4 9 C✓o e c 5+ ,4-.rc City/State/ZIP: $a v i-h. (,3 a r .J /N Y
Event Location (Please describe):
M04,+o✓ f/aa[ 6e4t. en roe et>t y Pc.j k- ,4w S.I3.
,F.. ^ a.h„t ^ . / Ll en ly - s t%t f -f A c -eat J l- e n.d .it.foK t do
6 C4%tecen jOoL. k d- +t,e r� Iesil P4"Il. Alle..j
Length of Event (Dates/Times): s .. d o% O t uh 2 1- 'Z: o D Ted opt
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 maybe 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 APPLICANTto these terms.
Signed on this Date:
. AuthorizeiT Organizer Signature
,Joan �Do...+tis
pr g w w t T ti'
Printed Name and Title
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.
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Applicant
Printed Name: 11-Z oI 'Do4 r, 5
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President
Member Member
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Member
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Date
to►. Support for Chapin Park Neighborhood Annual Halloween Party
I
Sunday October 3, 2024
Set Up 2:30 pm, Party 3-5 pm, Clean up 5-5:30 pm
I hear by give my consent and support for the neighborhood to
request that Manitou Place be closed to through traffic by the City of
South Bend Street Department briefly on Sunday October 28, 2024
for the Annual Neighborhood Halloween Party.
The street closure only means that regular through traffic will be not
be allowed during the event. Detours via LaMonte Terrance or
Riverside Drive are available.
n I recognize that access to my home will NOT be curtailed by vehicle
in an emergency. I also recognize that I do not need to move my
vehicle if it is parked on the street and that I may come or go from
the curb in my vehicle, I simply need to be careful and mindful of
people present. Parking your car off Manitou during the event is
appreciated if you know you need to drive it. This is however, not
required.
Name: Jo-�nus
Address: g o % eWk Avc.
Signature:
Date: �Izz�Z-�
Support for Chapin Park Neighborhood Annual Halloween Party
Sunday October, 2024
Set Up 2:30 pm, Party 3-5 pm, Clean up 5-5:30 pm
I hear by give my consent and support for the neighborhood to
request that Manitou Place be closed to through traffic by the City of
South Bend Street Department briefly on Sunday October �8, 2024
for the Annual Neighborhood Halloween Party. to
The street closure only means that regular through traffic will be not
be allowed during the event. Detours via LaMonte Terrance or
Riverside Drive are available.
I recognize that access to my home will NOT be curtailed by vehicle
in an emergency. I also recognize that I do not need to move my
vehicle if it is parked on the street and that I may come or go from
the curb in my vehicle, I simply need to be careful and mindful of
people present. Parking your car off Manitou during the event is
appreciated if you know you need to drive it. This is however, not
required.
Name: e hci_rle s � C?a-m l
Address:
Signature
Date:
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Support for Chapin Park Neighborhood Annual Halloween Party
Sunday October 26, 2024
Set Up 2:30 pm, Party 3-5 pm, Clean up 5-5:30 pm
I hear by give my consent and support for the neighborhood to
request that Manitou Place be closed to through traffic by the City of
South Bend Street Department briefly on Sunday October 28, 2024
for the Annual Neighborhood Halloween Party.
The street closure only means that regular through traffic will be not
be allowed during the event. Detours via LaMonte Terrance or
Riverside Drive are available.
I recognize that access to my home will NOT be curtailed by vehicle
in an emergency. I also recognize that I do not need to move my
vehicle if it is parked on the street and that I may come or go from
the curb in my vehicle, I simply need to be careful and mindful of
people present. Parking your car off Manitou during the event is
appreciated if you know you need to drive it. This is however, not
required.
Name: t-��C�cr-: ot- Zo�b
Address:¢ r' g'3\i'CW PL *
Signatur .
Date: q,O-D —a 4
• Support for Chapin Park Neighborhood Annual Halloween Party
Sunday October 2F1, 2024
Set Up 2:30 pm, Parry 3-5 pm, Clean up 5-5:30 pm
I hear by give my consent and support for the neighborhood to
request that Manitou Place be closed to through traffic by the City of
South Bend Street Department briefly on Sunday October 28, 2024
for the Annual Neighborhood Halloween Party.
The street closure only means that regular through traffic will be not
be allowed during the event. Detours via La Monte Terrance or
Riverside Drive are available.
I recognize that access to my home will NOT be curtailed by vehicle
in an emergency. I also recognize that I do not need to move my
vehicle if it is parked on the street and that I may come or go from
the curb in my vehicle, I simply need to be careful and mindful of
people present. Parking your car off Manitou during the event is
appreciated if you know you need to drive it. This is however, not
required.
Name: Kevin HLO)es
Address: L (D6 r'1Ctl'li tw PlRCe 30c)-th Bemd, D1 4.66 1/.
Signature:
l��
Date:
40
rMN Support for Chapin Park Neighborhood Annual Halloween Party
Sunday October 4 2024
Set Up 2:30 pm, Party 3-5 pm, Clean up 5-5:30 pm
t
✓ I hear by give my consent and support for the neighborhood to
request that Manitou Place be closed to through traffic by the City of
South Bend Street Department briefly on Sunday October 28, 2024
for the Annual Neighborhood Halloween Party.
The street closure only means that regular through traffic will be not
be allowed during the event. Detours via LaMonte Terrance or
Riverside Drive are available.
I recognize that access to my home will NOT be curtailed by vehicle
in an emergency. I also recognize that I do not need to move my
vehicle if it is parked on the street and that I may come or go from
the curb in my vehicle, I simply need to be careful and mindful of
people present. Parking your car off Manitou during the event is
appreciated if you know you need to drive it. This is however, not
required.
Name:Address:
Signature:
I -�
Signature: TII:YLI—
D
ate: 0� ��
BRIAN A KROSTENKO
JOAN DOWNS
574-383-6346
649 FOREST AVE
SOUTH BEND. IN 46616-1312
682
11-91%2712
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Pay to the
Order of C_Y o j •S C �"�
NOTRE DAME
PEUF.RAL CREDIT UNION
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