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APPLICATION <br />FOR USEOF, AND BLOCKING OF ACCESS TO, THE PUBLIC <br />RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES <br />The Board of Public Works inust 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 />El Fee Paid <br />Applicant Name: n <br />Address: City: <—" - 2� v_VD_ State: zip: q (_o(h <br />Phone: Email: t,!, U.DW-C CX_' <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 1rV0 <br />Location (\7V \N(A, _CA_ <br />(Describe Area/Route) <br />Street Closure Name ofStreet NN\'(NN"�ao' <br />From '�D'r _ <br />Date of Event cis:! 01 20 12L <br />El a.m. F-1 a.m. El a.m. <br />Time: Registration/Setup 'ap-m, Start End C, [].p.m. <br />Approximate Number of Attendees 90 <br />Answer the following appropriately: <br />1. This event will have music (live or other). El Yes No <br />a. I understand the Noise Ordinance described in the Agreement/Permit Yes E] 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 50 1 (c)(3) <br />hitemal Revenue Exemption Status Document and a current copy of <br />Form 990 of 990-EZ are included with this application, and Yes ❑No <br />additionally filed with the Office of the City Clerk, 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 Yes No <br />e. A copy of a flyer or door hanger that has been distributed to all Yes No <br />affected property owners. <br />3. el <br />a. This event involves City streets 0 Yes No <br />b. This event involves County roads El Yes No <br />c. This event involves State highways D Yes s0' No <br />Updated 812017 1 <br />