Street Closure - Archie Donaldson

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APPLICATION Z FOR THE USE OF AND BLOCKING OF ACCESS TO THE PUBLI -y � RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY �� The Board of Public Works must have four (4) weeks prior notice of the event`.86s A NONREFUNDABLE 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 h� `� _:A� v,r1Q.t CQ S-0,0 Address: C a,J City: 5 o L&t.�'�� ,� State: �,��, Zip Phone: 315 - a o $ r% 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 holdiqg of the hereinafter described event: Event Name Street Closure Name of Street (�if 0_2n From �U 1 Date of Event R gw1,3 -_ 19 20 Time Setup �-��. ❑ Start ❑a.m.,R] End Ela-m. Mp"m. a.m. IN p.m. Approximate Number of Attendees � o —� 5 Please answer the following appropriately: • 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 Yes ❑ No copy of the flyer distributed is included. (H 0 N C N�� G �+J) • This event will have music (live or other). Yes ❑ No • Payment of $50.00 fee payable to City of South Bend included or: 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 Cleric, 4" Floor, County -City Building, 227 W. Jefferson Blvd., South Bend, Indiana. IF ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be served ❑ 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