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Cortinn k _ InrlPmnifu A 4lnlrl M.rmlPee AerPPmont <br />City of South Bend Special Events Committee <br />• InA.mnihr C. 14MA 6lermlPec Aoroomont <br />Date: ogllle/202ci Event Date: XE07EMA3ek 2942OZY <br />Event Name: J 7-a4,S,9,4xG — C4/Z C21�/St —1N <br />Organization: af}�/✓s4 8t/S <br />Anni;,�nf Ir"nnt�rtl Ah_mP• ITOFtN S'TR ii7/GOS <br />Applicant(Contact)Phone: CS%y� aE7—&0(6S Alt. Phone: fs7zfi al20 —.2c/93 <br />Email: 60PI)3�S 1S,0/2280 hOfMail • CDC <br />Address: '1/3 Ar• lTcv'FrSRSQN 73c-t/0 City/State/ZIP: A &H 49&VJ r -7 ✓ cF&(017 <br />Event Location (Please describe): <br />S i oN i 5 Bj- v6 <br />7e{{crsonZ ✓d 4. Wash.ti.yA57'1/1St.) ( /� <br />I ono h of Front Irl�tPc /Timocl• �UNOA7 i�•1 /�9 /�OZ.� rT'�Iyl NDD/V — J • O0 Poi <br />Insurance Amount: This event is insured for no less than $700,000 per occurrence and $1,000,000 in aggregate, <br />and the certificate of insurance includes a rider naming City of South Bend, Special Events Committee, and Board <br />of Pi rhlir Wnrir< ac arlriif;nnally inti irPrl fnrthP PVPnt <br />Organization Name: &99AW� Yi I-Ilf—✓klo agrees to indemnify, defend <br />and hold harmless the Civil City of South Bend, Indiana, from any liability, loss, costs, damages or expenses, <br />including attorney fees, which the Civil City of South Bend, Indiana, may suffer or incur as a result of any claims <br />or actions which may be made against the City, its agents, employees, or subdivisions by any person, including a <br />participant in the activity. arisine out of the approval of this reauest by the Civil Citv of South Bend. Indiana. <br />through the Board of Public Works, to close a portion of the public right-of-way for the event described above, <br />or for any harm or damage alleged to have occurred because of the holding of the special event. The <br />undersigned certifies that he/she is authorized to bind the APPLICANT to these terms. <br />eian.A nn thie Harp• O1%/ 9,LU2t-f <br />Authorized OrgYnizer Signature <br />• Jr... M . S 1R.4-rI60 r <br />Printed Name and Title <br />