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�CCE <br />FOR USE OF <br />AND BLOCKING OF SS TO, THE PUBLIC ITAO <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES <br />The Board of Public Works must have FOUR (4) weeks 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 />7 <br />ApplicantName: 161 <br />Address: City- S tate: zip: <br />Phone: Email: Y tw je.,r r 00 <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 <br />Street Closure Narne of Street <br />Fro in <br />In <br />Date of Event v') <br />am. <br />Time: Registration/Setup [I P. in. <br />Approximate Number of Attendees ito <br />(Describe Area/Route) <br />1:1 a. nil <br />Start P p.m. End <br />Answer the following appropriately: <br />1. This event will have nausic (live or other), <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />2. Required Information to .Accompany Application <br />a. Certified Check of Money Order in the Amount of $125.00, or: <br />b. For Certified Nonprofit Organizations. Copies of the 50 1 (c)(3) <br />Internal Revenue Exemption Status Document and a current copy of <br />Forin 990 of Form 990-EZ are included with this application, and <br />additionally filed with the Office of the City Clerk, 01 Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend , lndiaiia. <br />c. Certificate ofInsurance <br />d, Maps, drawings and setup plan of the area <br />e. A copy of a flyer or door hanger that has been distributed to all <br />affected property owners. <br />3. <br />a. This event involves City streets <br />b. This event involves County roads <br />c. This event involves State highways <br />Updated 9/2017 <br />Yes <br />Yes <br />Yes <br />❑ <br />No <br />D' <br />Yes <br />El <br />No <br />EK <br />Yes <br />0 <br />No <br />D"', <br />Yes <br />n <br />No <br />❑ Yes No <br />❑Yes No <br />1 <br />