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08 -08-' 17 15:06 FROM- South Bend Heritage T-318 P0002/0007 F-305 <br />_LCA. TN <br />FOR 1(7SE OFAN <br />n BL12CRING,OXACCIESS To Hlg <br />RIGHT-OF-WAY ME NON-M81 ENT Ai BLOC URMES <br />The Board of Public Works must have FOUR (4) weeks prior notice of the event. <br />A N'ON .]EEFUNDA BLF- APPLICATION TEE O)P $125,00, 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 />❑ Fee paid <br />Applicant Name; <br />t <br />Address: a ifLamy: �, Stater -- zip: (' [ <br />Phone. 'Vq-2t9- toe . <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 1 1� hipq6 Lm t u V') Le G' sl h aC „ R.(�.r(A <br />.1k a . — <br />Location <br />Area/Route) <br />Street Closure Warne of5treet <br />r rorn <br />To VArttm t.tT h 0 4- up +► I <br />date orf iEvexit 2t} � . <br />Time- Registration/Setup [3p.m. Start O p.ni. End <br />Approximate Number of Attendees �.d . <br />Answer the following appropriately: <br />1 _ This event will have music (live or other), <br />Eg-`Yos <br />❑ <br />No <br />a. I u derstemd the Noise Ordinance described in. the Agremnont/Permit <br />0 <br />Yos <br />❑ <br />No <br />2. Required Information to Accompany Application <br />a. Certified Check or Money Order in the Amount of $125,00, or: <br />b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) <br />Internal Revenue Exomption Status Document and a current copy of <br />Farm 990 of Form 990-12Z are included with this application, and <br />Yes' <br />❑ <br />No <br />additionally filed with the Office of the City Clerk, 41r' Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />c. Certificate oft surance <br />d. Maps, drawings of the area and setup plan <br />Yes <br />❑ <br />No <br />3. <br />a. This event involves City streets <br />`Byes <br />❑ <br />No <br />b. This event involves County roads <br />❑ <br />Yes <br />No <br />c. This event involves State highways <br />❑ <br />Yes <br />Eg"`� No <br />d. Tbis event involves the use of the sidewalk <br />E!r <br />Yes <br />❑ <br />Na <br />Updated 412015 1 <br />