2. City of Michigan City Board of Public Works and Safety Agenda Request Form
   The Board of Public Works and Safety meets on the 1st and 3rd Monday of each month at 8:30 a.m. in the City Council Chambers located in the lower level of City Hall.

4. In order to be placed on a Board of Works meeting agenda, Individuals, Businesses, or Organizations are required to complete and submit this Agenda Request Form including any supporting documents. The person submitting this request should attend the BOW meeting wherein the request appears on the BOW Agenda. Failure to attend the BOW meeting, may result in the dismissal of the request. 

6. The deadline for submitting the completed Agenda Request Forms and supporting documents is the Wednesday before the next regular Board of Works meeting. Agenda requests must be received in the City Clerk’s Office by 12:00 p.m. on the Wednesday before the scheduled board meeting. This deadline will be strictly enforced. No exceptions will be granted.
8. Please make sure that your contact information is accurate in case we need to get in touch with you.

10. A Certificate of Insurance (COI) showing a liability policy in full force and with limits of $2,000,000.00 aggregate and naming the City of Michigan City as an additional insured for this event must be attached to your application before being placed on the meeting agenda. In addition, the (COI) must comply with any rules, regulations, and policies adopted by Board of Works. 

12. Any questions regarding this request can be directed to the City Clerk’s Office at (219) 873-1410.
14. Date Submitted (today's date)*
    Date Submitted (today's date)
15. Requested Meeting Date*
    Requested Meeting Date
17. First Name*
18. Last Name*
20. Name of Organization/Business (if applicable)
22. Street Address*
23. Suite or Apartment Number
25. Mailing Address
    If different from street address
27. City*
28. State*
29. Zip Code*
31. Primary Phone*
32. Secondary Phone
34. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile
35. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
37. Email Address*
38. Fax Number
40. Type of Request (check one)*

    1. Streetlight
    2. Vendor License
    3. Street Closure
    4. Block Party
    5. Walk/Run
    6. Parade
    7. Other (please explain)
41. Explain other:
43. Date and Time(s) Requested*
    Date and Time(s) Requested Start Date

    Date and Time(s) Requested Start Time

    —

    Date and Time(s) Requested End Date

    Date and Time(s) Requested End Time
45. Description of Request*
47. ACKNOWLEDGEMENT OF RESPONSIBILITIES
    I understand that if the Board of Public Works and Safety grants my request, the following conditions and restrictions will apply:
49. 1.) It is my responsibility to provide and maintain proof of liability insurance for this event at my expense.
51. 2.) It is my responsibility to provide to the Board any additional licenses, permits and documentation for the event.
53. 3.) I agree to abide by all terms and conditions of the Board’s policy governing walks, runs, parades or other similar events.

55. 4.) I understand in consideration for approval by the Board for the use of sidewalks/streets and/or use of City's real or personal property for my event, the undersigned agrees and undertakes to hold the Civil City of Michigan City, Indiana, free and harmless from any liability loss, damages and expenses including attorney fees, which the Civil City of Michigan City may suffer or incur as a result of any claims or actions which may be made by any person, including a participant in said activity, arising out of the approval to use the sidewalks/streets and/or City's real or personal property indicated in Michigan City. I also understand that the closure of streets/sidewalks and/or use of City real or personal property does not exempt me or any participant from any federal, state or local City ordinances.

57. 5.) In order to ensure public safety during the event barricades are required for a street closure. I understand it is my responsibility to erect the barricades prior to the event, and to dismantle them when the event concludes.
59. 6.) Any violations of State law or Local Ordinances (i.e. loud music, public intoxication, or consuming alcohol on public right away) may result in the immediate termination of my permit by the Michigan City Police Department.
61. 7.) I understand if my application requires the hiring of off-duty police officers, it is my responsibility to contract the required number of officers prior to the event.
63. 8.) If a roadway is being closed to vehicular traffic, it is my responsibility to ensure that any property owners that are affected by the closure are notified, and that ingress and egress to their property is maintained.
65. I have read the above acknowledgement of responsibilities and I understand and agree to them. I also understand that this application may be denied based on any false or incomplete information.
67. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
69. Electronic Signature
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit Submit and Print

* indicates a required field