Non Res Block Party - St Joseph Grade School

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APPLICATION FOR USE OF, AND BLOCI(ING 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. ❑ Fee Paid Applicant Name: St. Joseph Grade School Address: 216 North Hill City South Bend State: IN Zip: 46617 574-210-9087 Jeb Phone: McNally 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 Nance St. Joseph Grade School Field Da Location St. Joseph Grade School and Parish Center (Describe Arei/Route) Street Closure Name of Street St. Louis From Colfax To LaSalle Date of Event May 31 20 17 ❑ ❑ a.m. X a.1a). 230 : X® Time: Registration/Setup SAM ❑ p.,17. Start 9AM ❑ p.m. End PM 1m)), Approximate Nninber of Attendees 600 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 Form 990 of Form 990-EZ are included with this application, and ® Yes ❑ No additionally filed with the Office of the City Clerk, 4°i 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 ® Yes ❑ No b. This event involves County roads ❑ Yes ® No c. This event involves State highways ❑ Yes ® No Updated 4/2015