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APPLICATION FOR SIDEWALK CAFt PERMIT <br />CITY OF Sourti BEND, INDIANA <br />DATE -:)k-- FEE PAID <br />Applicant's Legal Name Title Cer. <br />Business Name C <br />Address <br />24 <br />Telephone Number <br />Proposed Location and Description of Sidewalk Caf6 <br />Days of Sidewalk Cafd Operation <br />Hours of Sidewalk Calid Operation <br />Sun <br />Mon <br />Toes <br />Wed <br />Thurs <br />Fri <br />Sat <br />241.6 <br />G 1 11 <br />I&AC <br />I <br />The following information is REQUII& D for completion of a Sidewalk C06 Application: <br />1. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafd showing placement/dimensions of proposed <br />cafd <br />3, Completed/signed Agreement <br />4, Certificate of Insurance ($1,000,000/occurance and $300,000/persoll, naming the City of South Bond <br />as additional insured) <br />AFFIRMATION <br />1, the undersigned, agree that I will abide by all of the provisions of Section 18,-15 of the South Bend Municipal <br />Code and with all the provisions stated above as conditions of the issuance of this Permit. I further agree to <br />indemnify, defend and hold harmless the City of South Bend from any liability, loss, cost, damage or expenses, <br />including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a <br />sidewalk cafd as permitted herein. I do hereby certify and affirm that all the information given in this application is <br />true to the best of my knowledge. <br />Date Signature of Applicant <br />JC_ <br />Printed Alt� <br />(I , (") ' <br />Title <br />BOARD OF PUBLIC WORKS APPROVAL <br />President Member Member <br />Mdmber Member Date <br />RE'rURN FORM TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 * Fax: (574) 235-9171 <br />11 <br />