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Home My WebLink AboutPublic Parking Facility - The Cathedral of Saint JamesFor all municipal business license questions, contact: City of South Bend • Department of Community Investment 227 West Jefferson Blvd • Suite 1400 5 -South Bend, Indiana 46601 •574.235.5912 • F: 574.235.9021 Ren.Nv &00M G� 6C R(p 3,Q 1-7-M9 LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION - 4-39 I. APPLICATION TYPE Check One: New IL BUSINESS DATA A. Business Name' L N B. Business Address: ,�`A *,13 City: � ,ntJl C. Mailing Address (If different from above): City: D. Business Telephone Number: E. Business Fax Number: F. E-Mail Address: Ok - l C'f State: a--2, -. Renewal 1vti; Zip: Lllb�) -"1 Zip: G. Maximum Number of Vehicles that can be parked at facility atone time (95 H. Total Number of Parking Spaces at facility: aA I. Hours during which vehicles may be stored: -avy\ H. Premises are (check one): Leased by Applicant Owned by Applicant If Leased: Owner's Name: Owner's Business Address: City: Owner's Residential Address: City: State: State: J. InsZ}raSnce Carrier and Amount of Liability Insurance OR Bonding For Office use Only Application Filed JUL2ois �pu Iicc orks Ap Application Fee Paid u 6 in4l. License Fee Pai Sent to Dept. Jill 3 I,niq License Number Not Approved Reason 1 Zip: 0 and Amount of Bond: Of Public Works For all municipal business license questions, contact: City of South Bend , Department of Community Investment 227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021 LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION - 4-39 III. PERSONAL DATA A" A. Applicant's Legal Name: I�IE B. Residential Address: City. C. Residential Telephone Number: D. Residential Fax Nun E. Celephone Number: F. Position with Busine r State: Zip: q. a43-1 IV. OWNERSHIP A. Type of ownershiq (checl< one): Sole Proprietorship (If sole proprietorship, proceed to 1). Partnership (If partnership, proceed to 2), Corporation (If corporation, proceed to 3). 1. Sole Proprietor. Name: 3 City:Uu� 2. Partnership (List at least two (2) partners) Name #1: Residential Address: City: Name #2: Residential Address: City: 3. Corporation Legal name of corporation: _ Date and state of incorporation: 2 State: v IQ Zip: State: State: Zip: Zip: For all municipal business license questions, contact: City of South Bend • Department of community Investment 227 West Jefferson Blvd • suite 1400 s -South Bend, Indiana 46601 •574,235.5912 • 2574.235.9021 LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION - 4-39 IV. OWNERSHIP (Continued) A. Type of ownership (continued): 3. Corporation (continued) Resident Agent: Name: \Sr�rt to Title:{'— Business Address: ( � a tcsl (C� rOUJCC City: �Mi1 82 2 J 4A- State: jky3 Zip: 46(f01' % Officers: Name #1: \�jj G P IVyLL,c1 ✓ , Title: �.at..cy,n/ ti`i1;,✓.,h.0 Business Address: �\ City: ate: 10 Zip: 4(06a � Residential Address: City: State: Zip: Name #2: Title: City: ;Y4` Residential Address: City: Name #3: rA Title: n( 4e Business Address: _ City: Residential Address: City: U State: ( N Zip: Zip: State: Zip: 8 For all municipal business license questions, contact: City of South Bend -Department of Community Investment 227 West Jefferson Blvd -Suite 1400 S -South Bend, Indiana 46601 • 574.235.5912 • F: 574,235.9021 LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION - 4-39 V. INCLUDE COMPLETE RATE AND HOUR SCHEDULE WITH APPLICATION VI. INCLUDE A CERTIFICATE OF LIABILITY INSURANCE WITH THE CITY OF SOUTH BEND LISTED AS THE CERTIFICATE HOLDER VII. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION Vill. AFFIRMATION I, hereby, certify and affirm that all of the information I have given in this application is true and accurate to the best of my knowledge. I further certify that I have in no way attempted to mislead the City in this application by omitting facts known to me. I have read and understand the regulations of the Public Parking Facility license found in the City of South Bend Municipal Code, Section 4-39. Signature Date SOUTHIND01 MILT CERTIFICATE OF LIABILITY INSURANCE DAT7111200A'YYY) 7rvzols THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER The Church Insurance Agency Corp 19 E 34 St New York, NY 10016A304 CONTACT NAME: PHONE FAX AIC No Fxt: N No: ADDRESS: INSURERIS AFFORDING COVERAGE NAIL# INSURERA:Church Ins Co of Vermont 110669V INSURED Cathedral of St James INSURER B: 117 N Lafayette Blvd INSURER C: South Bend, IN 46601-1507 1 INSURERD: INSURER E : _ INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NIIII THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. III ADDL'$UBRT—POLICY EFF POLIbY EXP7 LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER MM/DDIYYYY MMIDD/YYYY LIMITS A I X COMMERCIAL GENERAL LIABILITY 1r�x I CLAIMS -MADE LJ OCCUR N N PP0006095 5/1/2016 5/1/2017 EACH OCCURRENCE 96B cE1 Ed occ IEs occur, 000PREMISES _MED EXP(Anyone person)000PERSONAL&ACV INJURV 0DDGEN'L AGGREGATE LIMIT APPLIES PER JECOT LOC GENERAL AGGREGATE 000POLICY H ,' - TODD TS_COMP/OPAGG000OTHER: — AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT E. eooident BODILY INJURV (Per person) $ ANYAUTO I ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accitlent _ ( ) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY�AMAGE Peraccident $ $ i I _ UMBRELLA LIAB OCCUR EACH OC_CURREN_CE $ .. AGGREGATE $ LI EXCESS AB _- —__. —AS _- I DE_D RETENTION $ .__ $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDEDi NIA' STATUTE ERH E.L.EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE—$ __ (Mandatory In NH) II yYes, describe under DESCRIPTIONOFOPERATIONSbelow I I ! E.L. DISEASE-POLICV LIMIT �S -- A Umbrella N N IIVPP0006095 5/1/2016 1 5/1/2017 (Excess Liability 4,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may he attached If more space is required) Church parking lot used as public facility, city named as an additional insured. The City of South Bend 227 W Jefferson Blvd., Ste 1400 South South Bend, IN 46601- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ) ACORD 25 (2014101) the ACORD name and logo are registered marks of ACORD reserved.