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APPLICATION FOR SIDEWALK CAFE PERMIT <br />CITY OF SOUTH BEND, INDIANA <br />DATE <br />FEE PAID <br />Applicant's Legal Name ) '(jrf 1Ze Y ' I n nn I t�ry Title 4 <br />64 ve1 wte <br />Business Name VPLeL gl'e.CJP00ItP 9 <br />q 5 �NI� <br />Address l q 11/ Mt`a 'ta1v iT loy;r<, 6?,�I J . I•'y' iwml <br />Telephone Number <br />Proposed Location and <br />I N p4,04T " 81/1%r1/1 <br />Days of Sidewalk C66 Operation <br />Hours of Sidewalk Caf6 Operation <br />Sun <br />Mon <br />Toes <br />Wed <br />Thurs <br />Fri <br />Sat <br />N_ <br />tI- (� <br />j�- A4A1 <br />y _ X 4q+ <br />The following information is REQUIRED for completion of a Sidewalk Caf6 Application: <br />I. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk caf6 showing placement/dimensions of proposed <br />caf6 <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend <br />as additional insured) <br />AFFIRMATION <br />I, the undersigned, agree that I will abide by all of the provisions of Section 18-15 of the South Bend Municipal <br />Code and with all the provisions stated above as conditions of the issuance of this Permit. I further agree to <br />indemnify, defend and hold harmless the City of South Bend from any liability, loss, cost, damage or expenses, <br />including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a <br />sidewalk caf6 as permitted herein. I do hereby certify and affum that all the information given in this application is <br />true to the best of my knowledge. <br />Date Sign 4f App ' ant <br />-f 1, L/ <br />Printed Name <br />CEO <br />Title <br />BOARD OF P LIC WORKS APPROVAL <br />President Member Member Olga- 'I / do(7 <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 • Fax: (574) 235-9171 • E-Mail: publicwks@southbendin.gov <br />