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6 Tft APPLICATION RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY`PRACE x The Board of Public Works must have four (4) weeks prior notice of the A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. Applicant Name: t-IOYZ �. k� Address: N- 6rMr-6e�City: S-ac(+` C"C' State: JK Zip quLOA Phone: 5_7q-.S-1q- U 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 Street Closure Name ofl—�� Street From Ke k tt c Date of Event `7 - L _ I _� 20 t1 Time Setup cc P1 Start q ,`bz) 12a•m• ❑ End (B;OD ❑a.m. Fdp.m. a.m. p.m. El p.m. Approximate Number of Attendees Please answer the following appropriately: • This event will be open to residents outside the immediate KA Yes ❑ No neighborhood. • All residents on the affected block have been notified and invited. A Yes ❑ No copy of the flyer distributed is included. • This event will have music (live or other). [7 Yes ❑ No • Payment of $50.00 fee payable to City of South Bend included or: [A Yes ❑ No • For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal ❑ Yes ❑ No Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are included with this application, and additionally filed with the Office of the City Clerk, 4`t' Floor, County -City Building, 227 W. Jefferson Blvd., South Bend, Indiana. IF ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be served n Alcoholic beverages will be sold ❑ Certified Check or Money Order for $400.00 must be submitted with application. ❑ • Application cannot be processed without deposit. • Deposit will be returned upon inspection of event area by the Board of Public Works. Updated 4/2013 1