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RESIDENT SIGNATURES <br />Page <br />o2 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 <br />as: <br />Q5111) 5 y 4 <br />from u n A" <br />to <br />r <br />0 <br />Street Name <br />Cross Street <br />Cross Street -- <br />Date of Event <br />1. <br />6. <br />Signature <br />Signature <br />Name <br />CIO <br />I IC,fC <br />Name <br />Address <br />Address <br />Phone No. <br />Phone No. <br />Date <br />Date <br />2. <br />7. <br />Signature <br />Signature <br />Name <br />Name <br />Address <br />Address <br />Phone No. <br />Phone No. <br />Date <br />Date <br />3. <br />8. <br />Signature <br />Signature <br />Name <br />Name <br />Address <br />i b 5 5 �-�ch� <br />Address <br />Phone No. <br />Phone No. <br />Date%"' <br />Date <br />4. <br />9. <br />Signature' <br />Signature <br />Name <br />���',�; <br />Name <br />Address <br />.31 a (.s—, t�, S L,)tf5 t,)� <br />Address <br />Phone No. <br />Phone No. <br />Date <br />Date <br />5 <br />10. <br />Signature <br />Signature <br />Name <br />Name <br />Address <br />Address <br />Phone No. <br />Phone No. <br />Date <br />Date <br />Updated 6/22/12 5 <br />