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Sounrse <br />04 ,vl;ilyy/l. o <br />/1q <br />R(1 <br />I865 APPLICATION FOR PLACEMENT OF <br />HONORARY SIGN AND OTHER HONORARY FEATURE <br />WITHIN THE PUBLIC RIGHT-OF-WAY OR ON PUBLIC PROPERTY <br />For Office Use Only: <br />Comments: <br />1. Applicant Inform: <br />Applicant's Name:/? <br />Applicant's Address: <br />Email Address: <br />2. Honorary Sign or <br />Application Complete <br />Petition Complete <br />dt5--1(Il2- <br />e.--mum uvee��ram �m omeei m �rcl oveeq �J�� t`'� �� Significance of Location to Honoree's Life: <br />Beard of Pulslic Worlig <br />1: Comer ofNorlh and South Street Example <br />3. Required Submittals: <br />Please submit the following items along with your request: <br />✓ A tuned statement of not less than 500 words describing the significance of the person being honored. <br />The statement should include detailed information about the proposed Honoree summarizing the <br />Honoree's accomplishments, and reasons as to why the person should be publically recognized. <br />✓ A petition of support for the proposed Honorary Sign or Honorary Feature. The petition should be <br />signed by not less than fifty (50) residents of the City of South Bend and must include the name, <br />address, signature and date of signing. The petition should be witnessed by one individual and must be <br />notarized prior to submittal. [Note: All information on the petition must be legible in order to be <br />considered.] <br />Upon submission of this Application, please allow four (4) weeks for staff to review, and presentation to the <br />City's Board of Public Works for final action. A letter will be sent to the Applicant indicating the Board's <br />decision. In the event that the Application is denied, the Fee will be refunded to the Applicant. <br />4. SIGNATURE OF APPLICANT <br />My application consists of the following items: (Please check) <br />Ek6ompleted Application Form plus one (1) copy <br />2T$100.00 Application Fee (Make checks payahle to: City of South Bend) <br />ed atement escribing the significance of the person being honored <br />t t <br />Stgnalure Q Dale <br />�i✓,2y �iS �" - <br />PrintedName Foml 091001 <br />