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FO <br />4$OUTH, <br />APPLICATION„ <br />THE USE OF AND BLOCKING OF ACCESS TO THE PUBL - <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY ku <br />X -­�- �� 8 <br />The Board of Public Works must have four (4) weeks prior notice of the <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 <br />INCLUDED WITH APPLICATION. <br />Applicant Name: V i I/ f i[ 'c-- -7— h. o rv, e) A) <br />Address: L11 f /V �F ity: ©, g c� State: :►! Zip <br />Phone: S -7 �% `� 3 ,..-, e L/ -7 7 <br />This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of <br />the specified public right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name <br />Street Closure Name of <br />Street I <br />From c 0 I c1 <br />Date of Event 4U06_ 1'( 20 <br />Time Setup ) CCUl-' Start End <br />,p.m. <br />F R__'m ). <br />Approximate Number of <br />Attendees <br />Please answer the following appropriately: <br />• This event will be open to residents outside the immediate <br />neighborhood. <br />• All residents on the affected block have been notified and invited. <br />A copy of the flyer distributed is included. <br />• This event will have music (live or other). <br />• Payment of $50.00 fee payable to City of South Bend included or: <br />• For Certified Nonprofit Organizations: Copies of the 501(c)(3) <br />Internal Revenue Exemption Status Document and a current copy <br />of Form 990 of Form 990-EZ are included with this application, and <br />additionally filed with the Office of the City Clerk, 41h Floor, <br />County -City Building, 227 W. Jefferson Blvd., South Bend , <br />Indiana. <br />❑a.m. ❑p.m. <br />10/ Yes ❑ No <br />Yes <br />❑ <br />No <br />Yes <br />❑ <br />No <br />Yes <br />❑ <br />No <br />❑ <br />Yes <br />❑ <br />No <br />IF ALCOHOL IS TO BE SERVED OR SOLD <br />Alcoholic beverages will be served ❑ JVD Alcoholic beverages will be sold ❑ 100 <br />Certified Check or Money Order for $400.00 must be submitted with application. ❑ <br />• AppIication cannot be processed without deposit. <br />• Deposit will be returned upon inspection of event area by the Board of Public Works. <br />Names and phone numbers of THREE security guards ❑ <br />• To monitor underage drinking. <br />Updated 4/2013 <br />1 <br />