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12. APPLICANT agrees to indemnify, defend and hold harmless the Civil City of South Bend, <br />Indiana, from any liability, loss, costs, damages or expenses, including attorney fees, which the <br />Civil City of South Bend, may suffer or incur as a result of any claims or actions which may be <br />made by any person, including a participant in the activity, arising out of the approval of this <br />request by the Board of Public Works to close a portion of the public right-of-way for the event <br />described above. <br />I have read the Application and Permit and the Agreement for the "Use ofRight-of Way for Special <br />Events" and I understand and agree to the above rules and regulations. I also understand that this <br />application .may be denied based on anyr,false of incomplete information. <br />Dated this �� day of i V 20 <br />APPLICANT Signature <br />Printed Name <br />BOARD OF PUBLIC WORKS APPROVAL <br />President J Me ex <br />Member <br />Member Me ber <br />Date <br />RETURN FORM TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, <br />Phone: (574) 235-9251 • Fax: (574) 235-917 ®E Mail: end' publicwks southb @ un.gov <br />