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APPLICATION FOR SIDEWALK CAFE PERMIT , <br />CITY OF SOUTH BEND INDL ,NA "s' - <br />DATE FEE PAID � $ <br />Applicant's Legal Name "t Ylek VtIr Title 61'✓ <br />Business Name r'r r-• ,s <br />Address. <br />Telephone Number <br />Proposed Location and Description of Sidewalk Cafe <br />Days of Sidewalk Cafe Operation Sun Mon Tues Wed Thurs Fri Sat <br />_...... <br />Hours of Sidewalk Cafe Operation ;� 1� �� r " <br />The following information is REQUIRED for completion of a Sidewalk Cafe Application: <br />I. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafe showing placement/dimensions of proposed <br />cafe <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($1,000,000/occurance and $300,000/person, naming the City of South Bend <br />as additional insured) <br />AFFIRMATION <br />I, the undersigned, agree that I will abide by all of the provisions of Section 18-15 of the South Bend Municipal <br />Code and with all the provisions stated above as conditions of the issuance of this Permit. I further agree to <br />indemnify, defend and hold harmless the City of South Bend from any liability, loss, cost, damage or expenses, <br />including attorney fees, which the City may suffer or incur as the result of any use of the public sidewalks for a <br />sidewalk cafe as permitted herein. I do hereby certify and affirm that all the information given in this application is <br />true to the best of my knowledge. <br />Date <br />President <br />en ber <br />Member Member <br />� "r f Applicant „ <br />6Lr., <br />Printed N t <br />( -VV <br />TitleAC WORK�'APPROVAL <br />RETURN FORM TO: <br />Board of Public Works <br />1316 County -City Building <br />227 West Jefferson Boulevard <br />South Bend, IN 46601 <br />Phone: (574) 235-9251 * Fax: (574) 235-9171 <br />Member <br />Date <br />31/-)/�;2_0/F <br />4 <br />e <br />