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Page of <br />We have been informed, agree to, and request that the Board of Public Works of the City of <br />South Bend authorize a block party in the area described as: <br />from ! V' I-cfo to <br />Street Name Cross Street <br />Date of Event la 6(� <br />1 Signature fJ,��, b. Signature <br />i <br />Name �_ - k0-M ���<LL�� � n <br />Address 7 %�T�'L `'� <br />Phone No. <br />Date 6 " 7 — I U <br />Signature �� <br />Name S Wf(/S <br />Address <br />Phone No. <br />Date <br />3. <br />Signature <br />Name <br />Address <br />Phone No. <br />Date <br />4. <br />Signature <br />Name <br />Address <br />5. <br />zuo �2.4c (tiC9Y�yG <br />��{- ���7> <br />Phone No. a/O -1L Q, <br />Date 7 J-Z� <br />Signature T-'f-t4 <br />Name 6a! O -y e o 5 <br />AddressaZ i s •�`� �`�' <br />Phone No. 5 ?-( 3G �' 07 <br />Date ( r % 02 <br />Name <br />Address <br />OPP <br />Cross Street <br />�C <br />au� <br />3 s. 6Cs <br />Phone No. J "7 <br />Date <br />7. <br />Signature <br />Name <br />Address <br />8. <br />C101 <br />Phone No. <br />Date <br />Signature v�Y, <br />Name *� <br />Address S <br />Phoife No 7 G <br />Date <br />Signature <br />Name <br />Address <br />Phone No. <br />Date <br />Signature <br />Name <br />Address <br />Phone No. <br />Date <br />Updated 9/2017 <br />