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_kPPLICATION FOR SIDEWALK CAFE, PERMIT <br />0-Tv 01F Sot) ND, INDIANA <br />DATE 4-1.0-_1.9 FEE PAID C <br />Applicant's Legal Name Jeffrey Harrison Title Owner <br />Business Name Ve etable Buddies <br />A(Wess 129N Michigan South Bend,, IN 46601 <br />Telephone Number 574-232-0954 <br />Proposed Location and Description of Sidewalk Cafd <br />.., gout of Vet?,etable Buddies <br />Days of Sidewalk Cafe Operation Sun Mon Tues Wed Thurs Fri Sat <br />.... _____!_q .m . ...... — _.1FI-i..._.. <br />Spm- Spm- Spm- � Spm- Spm- <br />-lours of Sidewalk Cafd Operation _NA NA 2am 2am 2am 2am 2am <br />The following information is REQUIRED for completion of a Sidewalk Cafd Application: <br />1. Completed/signed application, including a $10.00 fee <br />2. Drawing(s) and description of proposed sidewalk cafd showing placement/dimensions of proposed <br />e190fT <br />3. Completed/signed Agreement <br />4. Certificate of Insurance ($1.,000,000/occurance and $300,000/person, naming the Citv of South Ber.. <br />as additional insure <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 cafd 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. c <br />Date Si at r o1 A rlint <br />Jeffrev Harrison <br />Printed Name <br />a <br />Owner <br />Title i <br />BOARD OF PUBLIC WORKS APPROVAL <br />11l l*sIddJI11 a.. . ............. � ____� _ �r.....�._w -..... ..... <br />Member Member <br />ember Member Date <br />RETURN FORM TO: 4 <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 a Fax: (574) 235-9171 <br />