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APPLICATION <br />FOR USE OF AND BLOCKING OF ACCESS TO PUBLIC <br />RIGHT-OF-WAY FOR A RESIDENTIAL BLOCK PARTY <br />The Board of Public Works must have four (4) weeks prior notice of the event. <br />A NON-REFUNDABLE APPLICATION FEE OF $50.0,0, 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 />Applicant Name: <br />Organization: <br />Address: <br />Q,� <br />city: <br />State: <br />Zip <br />Phone: <br />Email: <br />Secondary Contact <br />Address: <br />City: — State: <br />Phone: Email: <br />This application is made to the City of South Bend, Indiana, BoardofPublic Works, <br />for the use of <br />the specified ublic right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name <br />Name of <br />Street Closure <br />Street <br />From <br />To <br />Date of Event <br />120 1 <br />Time <br />I Setup <br />a-m-EIP.M. Start <br />a.m. E]P.m. <br />End <br />a.m. <br />P. <br />Time <br />i" <br />Time <br />Approximate Number of <br />Attendeesit <br />Z4 <br />Z <br />Please answer the following Mpropriately: <br />-0—No <br />• This event will be open to residents outside the immediate <br />17T—'Yes <br />neighborhood. <br />• All residents on the affected block have been notified and invited. A <br />_n <br />Yes <br />El <br />No <br />copy of the flyer distributed is included, <br />• There is/are resident(s) affected by the event that may need ADA <br />_ET <br />es <br />No <br />transportation assistance to their residence. <br />• This event will have music (live or other). <br />Yes <br />M <br />No <br />• Payment of $50.00 fee payable to City of South Bend included <br />Yes <br />No <br />0 For Certified Nonprofit Organizations: Copies of the 5 01 (c)(3) Internal <br />Yes <br />No <br />Revenue Exemption Status Document and a current copy of Form 990 <br />or Form 9,90-EZ are included with this application. <br />Updated 06/2017 <br />