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I have read the Application and Permit and the Agreement for the "Use of Right -of -Way for Block Parties" <br />and I understand and agree to the above rules and regulations. I also understand that this application may be <br />denied based on any false or incomplete information. <br />Dated this day of <br />APPLICANT Signature ►t--� <br />Printed Name l `e 7--P r, 1 t <br />,,.BOARDOFP4BLICWOR S APPROVAL <br />President Member Member <br />Member Member Date <br />RETURN FORM TO: _ <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 0 Fax: (574) 235-9171 9 E-Mail: publicwks@southbendin.gov <br />