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APPLICATION <br />y <br />FOR THE USE OF, AND BLOCKING OF, ACCESS TO THE PUBLI­ ..n <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY PE. <br />x <br />The Board of Public Works must have four (4) weeks prior notice of the event." <>;,65;::-=` <br />A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM OF A CERTIFIED <br />CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE 1\� <br />INCLUDED WITH APPLICATION. <br />Applicant Name: �� rn(''V¢, i �( f <br />Address; I) U'ti 1� tAodr�ity: �j 13 State: �' � Zip <br />Phone; S7 _? 4 , 29 �/ _ �' q O'�i <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the <br />specified public right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name (VX0AI S+. � 1- �, /a c A/_ w <br />Street Closure Name of tM <br />Street <br />From o t aw Y) <br />To 001 I i lr l <br />Date of Event S (,,�,�1,1 L.-� rr 20 Q <br />Time Setup '6; 3u � Start ❑a.m El End <br />J <br />`©� ❑a.m. m. <br />-a.m. p.m. <br />. <br />p.m. <br />Approximate Number of iso <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate <br />❑ Yes g No <br />neighborhood. <br />• All residents on the affected block have been notified and invited. A <br />r5' Yes ❑ No <br />copy of the flyer distributed is included. <br />• This event will have music (live or other). <br />❑ Yes 0 No <br />• Payment of $50.00 fee payable to City of South Bend included or: <br />Yes ❑ No <br />• For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal <br />Yes [4 No <br />Revenue Exemption Status Document and a current copy of Form 990 <br />of Form 990-EZ are included with this application, and additionally <br />filed with the Office of the City Clerk, 4'h Floor, County -City Building, <br />227 W. Jefferson Blvd., South Bend, Indiana. <br />IF ALCOHOL IS TO BE SERVED OR SOLD <br />(� <br />Alcoholic beverages will be served ❑ Alcoholic beverages <br />will be sold ❑ <br />Certified Check or Money Order for $400.00 must be submitted with application. <br />❑ <br />• Application cannot be processed without deposit. <br />• Deposit will be returned upon inspection of event area by the Board of Public <br />Works. <br />Updated 4/2013 1 <br />