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M 1112113211 n M I M <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 />F] Fee Paid <br />Applicant Name: <br />Address: City: 91'pkXg -J�, q4.jtate: zip <br />Phone: Email: Lt <br />C <br />This application is made to the C tyy of South Bend, dia. Boa0d of Public Works, for the use of the <br />specified public right-of-way by Applicant for the ho 6ng of the hereinafter described event: <br />Event Name <br />Location <br />Street Closure <br />Date of Event <br />Time: Registral <br />Approximate Number of Attendees _ <br />'P <br />Answer the following appropriately: <br />e <br />1. This event will have music (live or other). <br />El Yes No <br />a. I understand the Noise Ordinance described in the Agreement/Permit <br />VYes No <br />2. Required Information to Accompany Application <br />a. Certified Check or Money Order in the Amount of $125.00, or: <br />b. 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 />HillYes F] No <br />additionally filed with the Office of the City Cleric, 4" Floor, County - <br />City Building, 227 W. Jefferson Blvd., South Bend, Indiana, <br />c. Certificate of Insurance <br />d. Maps, drawings and setup plan of the area <br />IE/ Yes No <br />e. A copy of a flyer or door hanger that has, been distributed to all <br />51-�Yes No <br />affected property owners, <br />3. <br />a. This event involves City streets <br />Ej/yes 0 <br />b. This event involves County roads <br />Yes N"�-�T <br />F1 o <br />c. This event involves State highways <br />Yes No <br />Updated 8/2017 <br />1 <br />