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APPLICATION <br />FOR USE O.I++' AND BLOCKING OF ACCESS TO THE PUBLIC <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES <br />The Board of Public Works must have FOUR (4) weeps prior notice of the event. <br />A NON-REFUNDABLE APPLICATION FEE OF $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 Nanae: trQi (_c <br />Address:-,� 4d- city:State: _Z) Zip: <br />Phone: S_-)4—Q'j S7 Email: r ,Sae•-1C . e �.a r rn ,C S.__ G • Dr <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 <br />Location A00 1'r�'T'z2le� <br />(Describe ArcdRoute) <br />Street Closure Name ofStrect 4" i <br />From <br />To <br />Date of Event ?� ' 1_ — 20 <br />r ��� j a 111. <br />I'irr►e: Reg s€rafii�ni�Setup �� � ❑l P.1m Start <br />Approximate Number of Attendees 500 "" )00 <br />,4 00 .m. ❑ a.111. <br />C3 ❑ p.m, Enid � E+�. n. <br />Answer the following appropriately: <br />l . 'Phis event will have music (live or other). <br />Yes <br />❑ <br />No <br />a. I understand the Noise Ordinance described in the Agreement/Pernait <br />[4 Yes <br />❑ <br />No <br />2, Required Information to Accompany Application <br />a. Certified Check or Money Order in the Announrt of $125.00, or: <br />b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) <br />Internal Revenue Exemption Statics DOeunleilt and a current copy of <br />Form 990 of Form 990-EZ are included with this application, and <br />Yes <br />❑ <br />No <br />additionally filed with the Office of the City Cleric, 41" Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />c. Certificate of Insurance <br />d. Maps, drawings and setup plan of the area <br />�es <br />❑ <br />No <br />e. A copy of a flyer or door hanger that has been distributed to all <br />`']IYes <br />❑ <br />No <br />affected property owners. <br />3. <br />a. This event involves City streets <br />Yes <br />❑ <br />No <br />b. This event involves County toads <br />❑ Yes <br />A-­'yNo <br />c. This event involves State highways <br />[❑ Yes <br />[q----No <br />Updated 8/2017 <br />1 <br />