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APPLICATION <br />TO <br />FOR USE OF AND BLOCKING OF •. PUBLI <br />The Board of Public Works must have four (4) weeks prior notice of the event. <br />A NON-REFUNDABLE APPLICATION FEE OF $50.00, IN THE FORM 4F A CERTIFIED <br />CHECK CAR MONEY GIRDER, PAYABLE TO THE CITY 4F SOUTH BEND, MUST BE <br />INCLUDED WITH APPLICATION. <br />Applicant Name: <br />�U 0 <br />Organization: <br />State: <br />Zip. <br />Address: <br />Phone: <br />Email: A; <br />Secondary Contact <br />°I <br />& <br />_Age <br />Address; c)r6\-\Q <br />City: State. <br />Phone.��.'� � —"�"d. Email: <br />This application is made to the City of south Bend, Indiana, Board of Public Works, for the us of <br />the specified public right-of-way by Applicant for the holding of the hereinafter described event: <br />Event Name <br />_ <br />Name of <br />Street Closure <br />Street <br />From <br />St <br />To <br />Date of Event <br />, �c <br />20 <br />Ti�nne <br />Setup <br />a.m. .m. <br />Start <br />❑a.m. ,m, End l❑a,m, <br />j <br />Time <br />Time <br />p.m. <br />Approximate Number of <br />Attendees <br />oc) <br />Please answer the following appropriately: <br />a This event will be open to residents outside the immediate <br />Yes <br />❑ <br />No <br />neighborhood. <br />® All residents on the affected black have been notified and invited. A <br />Yes <br />❑ <br />No <br />copy of the flyer distributed is included. <br />o There is/are resident(s) affected by the event that may need ADA <br />El <br />Yes <br />No <br />transportation assistance to their residence, <br />• This event will have music (live or other). <br />Yes <br />No <br />• Payment of $50.00 fee payable to City of South Bend included <br />El <br />Yes <br />No <br />Updated 08/2017 <br />