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N APPLICATION FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC ` RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY The Board of Public Works must have four (4) weeks prior notice of the event. 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: % r -a- , W k Organization: _ �; -� f"- ��) � C1�_ , Address: -City: _ _ State: zip Phone: % ! �� 1 c L v V ' Email: Secondary Contact � - -- 0, n � Address: -/_�6R7 F . V\l C t City: _ _C c 1 �l'� B,,:��tl State: Phone: _ c � i -� 3 C C � Email: C e' C1 C n A. t � : This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of r � <% I i specified public right-of-way by Applicant for the holding of the hereinafter described event: l Event Name CAS - ll n (..-V n (:f—. `��r JVI c_ Name of Street Closure Street �G �"j C �_ 1" C7 5+ C",_ so From To U GO O Date of Event c_S t) C [ j a 20 1 7 c)N Start Time Setup Time �fu O0 Approximate Number of Attendees G Please answer the following appropriately: f VC End ❑a.m.N""p.m. Time ❑a.m. Zp.M. • This event will be open to residents outside the immediate ❑ Yes No neighborhood. • All residents on the affected block have been notified and invited. A jj Yes ❑ No copy of the flyer distributed is included, • This event will have music (live or other). Yes ❑ No • Payment of $50.00 fee payable to City of South Bend included • For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal Yes ❑ No Revenue Exemption Status Document and a current copy of Form 990 or Form 990-EZ are included with this application. IF ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ Updated 06/2017 I