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APPLICATION FOR USE OF, AND BLOCKING OF ACCESS TO, THE PUBLIC RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES The Board of Public Works must have FOUR (4) weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. X (` ' ""' � �a1 Fee Paid`'ApplicantName: le ©ed / 9 Address: 7VO 6_j , 01C�/, n�ity: , 7 State: -� � Zip: � Phone: 7� This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name LocationT� Z (Describe ArewRoute) Street Closure Name of StreetOQ! From To Date of Event 20 f(.p Time: Re istration/Setu C> E j air � g P v: P L�p.m. Start � 0 0 m. 00 �. End % - m Approximate Number of Attendees Answer the following appropriately: 1. This event will have music (live or other). Yes ❑ No a. I understand the Noise Ordinance described in the Agreement/Permit Yes ❑ No 2. Required Information to Accompany Application a. Certified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal Revenue Exemption Status Document and a current copy of No Form 990 of Form 990-EZ are included with this application, and ❑ Yes [ l� additionally filed with the Office of the City Clerk, 4th Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana. c. Certificate of Insurance d. Maps, drawings of the area and setup plan [Yes ❑ No 3. a. This event involves City streets E9 Yes ❑ No b. This event involves County roads ❑ Yes ❑-�No c. This event involves State highways ❑ Yes ❑/ No d. This event involves the use of the sidewalk ❑ Yes E__�No Updated 4/2015