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APPLICATION <br />FOR USE OF, 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) 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 />//���� <br />ee Paid .. <br />Applicant Name: Sunnw-Jf �re5 �-� 64t,, <br />J <br />Address: 1 S t o �� City: �t41..... State; r�jj% Zip: eK <br />Phone: (7N 1 7.87-1 SZ4 Email: <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 411 <br />C.,tn <br />�. <br />Location 1 �� <br />r' <br />s <br />.-c.k i <br />Street Closure Name of Street S G I&YN(ks S� <br />From <br />To <br />Date of Event —Ta,Rp 17 20 <br />Pg-'a.m, <br />Time: Registration/Setup c ❑ p,m, <br />Approximate Number of Attendees <br />Ma.m. <br />Start q ❑ p.m. End <br />Answer the following appropriately: <br />1. This event will have music (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 or Money Order in the Amount of $125.00, or: <br />fiv For Certified Nonprofit Organizations: Copies of the 501(c)(3) <br />Internal Revenue Exemption Status Document and a current copy of <br />Form 990 of Form 990-EZ are included with this application, and <br />additionally filed with the Office of the City Clerk, 4`i' Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana. <br />Certificate of Insurance -- 6-v S `n.o,,*(d "% 11Q- �-► �• l � <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. a, �u.�� ,'s �� ohl� b,; IA- <br />3 <br />a. This event involves City streets <br />b. This event involves County roads <br />c. This event involves State highways <br />o.• too B�oGI; er "� <br />on <br />Z ❑ a.m. <br />�' p.m. <br />Yes No <br />Yes ❑ No <br />[� Yes ❑ <br />❑ �, Yes ❑ <br />Yes ❑ <br />Yes ❑ <br />Yes []� <br />Yes <br />No <br />No <br />No <br />No <br />No <br />Updated 8/2017 <br />