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�4SOUTiI pE tid APPLICATION FOR USE OF, AND BLOCKING OF ACCESS TO THE PUBLIC wl, aGR s RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES rxe, The Board of Public Works must have FOUR (4) weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. ❑ Fee Paid Applicant Name: Address: '424(o S HA�ntl City: S U State: 1 r4 Zip: 4 6G ! Phone: 233..I2,o Ceu.) This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name W UyS r 5 r o¢ \nle n r-I es D om Location 2 `b o p coc tc W . w11,s -fit rf (Describe Area/Route) Street Closure Name of Street 1. x L .n '_' From W b` T1,;, 2 V-j To W. S�LGf(e(LSoo Date of Event � V� O 20 1(, ❑ a.m. ❑ a.m. ❑ a.m. Time: Registration/Setup f 00 Rp.m. Start S' 0' f p.m. End 10' 00 (Rp,m, Approximate Number of Attendees 2 S-O Answer the following appropriately: 1. This event will have music (live or other). a. I understand the Noise Ordinance described in the Agreement/Permit 2. Required Information to Accompany Application a. Certified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are included with this application, and additionally filed with the Office of the City Clerk, 41 Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana. c. Certificate of Insurance 3 d. Maps, drawings of the area and setup plan a. This event involves City streets b. This event involves County roads c. This event involves State highways d. This event involves the use of the sidewalk Yes ❑ No Yes ❑ No 9 Yes ❑ No 0 Yes ❑ No ® Yes ❑ No ❑ Yes ® No ❑ Yes 2 No Er Yes ❑ No Updated 4/2015 1