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YPACP. DATE Applicant's Legal Name Business Name Address Telephone Number APPLICATION FOR .SIDEWALK CAFE PERMIT CITY OF SOUTH BEND, INDIANA H. Meehan 103 West Colfax, South Bend, IN 46601 574-232-9200 Proposed Location and Description of Sidewalk Cafe FEE Title Partner/Secy-Treas Sidewalk adjacent to the building at the NW comer of Colfax & Michigan Streets Days of Sidewalk Cafe Operation Hours of Sidewalk Cafe Operation Sun Mon Tues Wed Thurs Fri Sat llam- 10 m Ilam- 10 m 10 m 10 m 10 m 1 Opm The following information is REQUIRED for completion of a Sidewalk Cafe Application: 1. Completed/signed application, including a $10.00 fee 2. Drawing(s) and description of proposed sidewalk cafe showing placement/dimensions of proposed cafe 3. Completed/signed Agreement 4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend as additional insured) AFFIRMATION I, the undersigned, agree that I will abide by all of the provisions of Section 18-15 of the South Bend Municipal Code and with all the provisions stated above as conditions of the issuance of this Permit. I further agree to indemnify, defend and hold harmless the City of South Bend from any liability, loss, cost, damage or expenses, including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a sidewalk cafe as permitted herein. I do hereby certify and affirm that all the information given in this application is true to the best of my knowledge% 3/3/17 '7 �! 6 1& Date Signature of Applicant Carol H. Meehan Printed Name Partner/Secretary-Treasurer Title OARD OF PUBLIC WORKS APPROVAL /' President - Member Member Member Member RETURN FORM TO: Board of Public Works 1316 County -City Building 227 West Jefferson Boulevard South Bend, IN 46601 .a//q�,2° /7 Date 0