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HomeMy WebLinkAboutPublic Parking Facility - MC Investments LLCTO: INTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT: 1/11/2017 /Randy Wilkerson, Code Enforcement Jrfederico Rodriguez, Fire Department att Longfellow, Engineering hris Dressel, Community. Investment FROM: Linda M. Martin, Clerk ' A� SUBJECT: License Application forl'Public Parking Facility MC Investments, LLC LOCATION: DATE DUE FAX OR E-MAIL TO: 214-216 W Wayne St. 117 S William 123 N Main 01 /17/2017 235-9171 / Imartin@southbendin.gov RECOMMENDATIONS AND COMMENTS: By Date 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 CK1�37� 8 ��5.m LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION -4-39 I. APPLICATION TYPE Check One: New Renewal XXX II. BUSINESS DATA A. Business Name: MC Investments, LLC B. Business Address: 214-216 W. Wayne St. City: South Bend State: IN C. Mailing Address (If different from above): 1428 Hamilton Ave. City: Cleveland State: OH D. Business Telephone Number: al �� 5 E. Business Fax Number: 2 A F. E-Mail Address: ( / id 4 P k1j I G. Maximum Number of Vehicles that cah be parked at facility at one Zip: 46601 Zip: 44114 H. Total Number of Parking Spaces at facility: (Z 0 I. Hours during which vehicles may be stored: _ 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: J. Insurance Carrier and Amount of Lh State: State: Zip: Zip: Insurance OR Bonding Agent and Amount of Bond: For Office Application Filed JAN 0 9 20 EuWl tnr ks�Apo2oval Application Fee Paid JAN U V ZU17 License Fee Paid JAN 0 9 2017 Sent to Dept. JAN D-2W License Number 17.773% Not Approved Beard oPPuNic uL1ic Works Reason 1 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. Applicant's Legal Name: _ / `/ i i/N/ice U J1 B. Residential Address: % 1 Mgt L on City: (.I oyj) n state: Zip: C. Residential Telephone Number: D RPSIfIPntlal Fax Numher: E. Cellphone Number: F. Position with Busine IV. OWNERSHIP A. Type of ownership (check 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: Residential Address: City: State: Zip: Telephone Number: 2. Partnership (List at least two (2) partners) Name #1: Residential Address: City: Telephone Number: Name #2: Residential Address: State: Zip: City: State; Zip: Telephone Number: 3. Corporation Legal name of corporation: NV Ll r "m t 6 J I Al Date and state of incorporation: T/ % I q W - 61 q 1A oht 2 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 IV. OWNERSHIP (Continued) A. Type of ownership (continued): 3. Corporation (continued) Resident Agent: _nn / �j�f Name: t 7 C $�` Af Title: t� Businesss�--Addr/esss: (!_,'a / City: % t' 1 V , 0 State: Zip: Officers Name#1: l° I(ti' ( ! AlAl>✓ Title: M ["M/' 1c- Business Address: `7 Lair �IUti�/ City: State: Zip: Residential Address: City: State: Zip: Name #2: Title: Business Address: City: Residential Address: City: Name #3: Title: Business Address: Citv: Residential Address: City: 3 State: State: State: State: Zip: Zip: Zip: Zip: 0 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 D� U VI. INCLUDE A CURRENT INSURANCE POLICY OR BOND 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. 1 Signature Date MARYC-1 OP ID: KL ACC CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDDIYYYY) 01106/2017 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 Oswald Companies 2000 Polaris Parkway P. O. Box 728 Columbus, OH 43216.0728 James B. Oswald Company House INSURED 44114 NAMEpVI James B. Oswald Company House PHON. �..,.888-323-1383 INC. Nor. 614-796-7728 NI IMRFR: V 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. INSR LTR TYPE OF INSURANCENOOL sD wv0 POLICY NUMBER OLICY EFF MMIDD POLICY EXP MM/DD/YYYV LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE FXIOCCUR CWP0817747 02I1412016 0211412017 °PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 5,000 PERSONAL SADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS- COMPIOPAGG $ 2,000,000 POLICY PELT LOC OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ A ANYAUTO CWPOB17747 02/1412016 0211412017 BODILY INJURY (Per aWdenl) $ ALLOWNED x SCHEDULED HII EOSAUTOS NON OWNED AUTOS X X UTOS PROPERN DAMAGE (Per accident) $ J( UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 A EXCESS LIAB CLAIMS -MADE CWPO817747 0211412016 0211412017 OEO I X I RETENTION$ 0 $ 1 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEMUECUTNE ❑NIA OFFICERIMEMBER EXCLUDED? (Mandatory in NH) PER I I ERH E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYE $ E.L.OISEASE- POLICY LIMIT $ Ifyea, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPE NATIONS I LOCATIONS I VEHICLES (ACORD 101, AddMonal Remarks Schedule, maybe attached If more apace Is requlmd) RE: 214 W Wayne St, South Bend, IN 46601 117 S William St, South Bend, IN 46601 123 N Main St, South Bend, IN 46601 _--.--_-----_-- CITYSO- Cif Of South Bend Y SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 125 S Lafayette Blvd #100 ACCORDANCE WITH THE POLICY PROVISIONS. South Bend, IN 46601 AUTHORIZED REPRESENTATIVE ew�.-1 FJTeee-LVIYHVVRV NVRr'VRMIIVIY. nu uyn o,coc,vvu. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD For all municipal business license questions, contact: City of South Bend • Department of Community Investment p� 227 West Jefferson Blvd • suite 1400 S -South Bend, Indiana 46601 • 574.235.5912 �74.3778 �' 0:.7 -CO LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION -4-39 I. APPLICATION TYPE Check One: New Renewal XXX II. BUSINESS DATA A. Business Name: MC Investments, LLC B. Business Address: 117 S. William St. City: South Bend C. Mailing Address (If different from above): City: Cleveland D. Business Telephone Number: E. Business Fax Number: 9-7G F. E-Mail Address: —State: IN 1428 Hamilton Ave. State: OH Zip: 46601 Zip: 44114 G. Maximum Number of Vehicles that can be parked at facility at one time: S, H. Total Number of Parking Spaces at facility: T� J I. Hours during which vehicles may be stored: 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: Zip: Zip: 1. Insurance Carrier and Amount ndAmount of Liability Insurance OR Bonding Agent and Amount of Bond: For Office Use Only Application Filed JAN 0 9 2017 Public Works A , al Application Fee Paid _JAN o 9 2017 License Fee Paid Sent to Dept. JAN 0 U ZU17 LicenseNumber__1%�1J%Jc Not Approved Reason 1 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. Applicant's Legal Name: B. Residential Address: City: ( rV_(2'±0 State: C44 Zip: LIVT_ C. Residential Telephone Number: D. Residential Fax Number: E. Cellphone Number: ) / ( �c) 0,A ( 7 F. Position with Business: /°1 6117122 1/1- _ IV. OWNERSHIP A. Type of ownership (check 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: Residential Address: City: Telephone Number: 2. Partnership (List at least two (2) partners) Name #1: Residential Address: City: Telephone Number: Name #2: Residential Address: City: Telephone Number: State: State: FM Zip: State:., Zip: 3. Corporation Legal name of corporation: /V? C V—t J L Date and state of incorporation: �9 / `(/1-11 2 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 IV. OWNERSHIP (Continued) A. Type of ownership (continued): 3. Corporation (continued) Resident Agent: / Name: rVtly yf47 Title: Business Address: 1r� �77StS ��1 G City: _ / 7 L` b State: Zip: Officers Name #1: �11 Title: M i del, Business Address: ArJ2aycr City: State: Zip: Residential Address: City: State: Zip: Name#2: Title: Business Address: City: Residential Address: City: Name #3: Title: Business Address: City: Residential Address: City: 3 State: State: State: State: Zip: Zip: Zip: For all munlcipaI business license questions, contact: City of South Rend • 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 CURRENT INSURANCE POLICY OR BOND 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 tome. 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 MARYC-1 OP ID: KL CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD YYY) 01/06/2017 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 Oswald Comp antes 2000 Polaris Parkway P. O. BOX 728 Columbus OH 43216.0728 James B. bswald Company House CONTACT James B. Oswald Company House PHONE Ewt:gg8-323.1383 ac No: 614-796-7728 E-MAIL ADoaess: INSURERS AFFORDING COVERAGE NAICa INSURERA:Westfield Insurance Company 24112 INSURED Mary Coyne Investments LLC Coyne Investments LTD 1428 Hamilton Ave INSURERS: INSURER C; Cleveland, OH 44114 INsuRERD: INSURER E: INSURER F: nrrv�w rc NUMBER: N - REVISION NUMBER: COVERAGE. uvvsr. •. 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. IN R LTR TYPE OF INSURANCE INSD POLICYNUMBER N, DPOLIO Ell MPOLIC P MIDDffYYV LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR CWPO817747 02114/2016 0211412017 PREMISES We occunenee $ 500,000 MED EXP (Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ JECT PRO' POLICY El LOG GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acciderd $ 1,000,000 BODILY INJURY (Per person) $ A ANYAuTo CWPO817747 02/1412016 02/1412017 BODILY INJURY(Peraccidenl) $ ALLOWNED )( SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS PROPER AMAGE Per accident $ S A X UMBRELLA LIAM EXCESS LAB X OCCUR CLAIMS -MADE CWPO817747 02114/2016 02114/2017 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED I X I RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTME YIN OFFICERIMEMBER EXCLUDED? (Mandatory in NH) STATUTE ERH E.L. EACH ACCIDENT $ E.L. DISEASE -FA EMPLOYE $ E.L. DISFA3E-POLICY LIMIT $ I%yft, describe underOPERATIONS below DESCRIP ION OF DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Romance Schedule, may be aVachad It more space Is required) RE: 214 W Wayne St, South Bend, IN 46601 117 S William St, South Bend, IN 46601 123 N Main St, South Bend, IN 46601 reNCE L ATION CER1 iFICA r C HCLCcrv...____...._._ CITYSO- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of South Bend THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 125 S Lafayette Blvd #100 ACCORDANCE WITH THE POLICY PROVISIONS. South Bend, IN 46601 AUTHORIZED REPRESENTATIVE 197BCe•2U74 HrrVKU I,VRfVRNItV1Y. flu rrynw rcaw vas. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD For all munlcipaI business license questions, contact: City of South Bend • Department of Community Investment 227 West Jefferson Blvd • Suite 14005 -South Bend, Indiana 46601 •574.235.5912 • F:574.235.9021 CK*3778 $95,00 LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION - 4-39 I. APPLICATION TYPE Check One: New II. BUSINESS DATA A. Business Name: MC Investments, LLC Renewal B. Business Address: 123 N. Main St. City: South Bend State: IN C. Mailing Address (If different from above): 1428 Hamilton Ave. City: Cleveland State: OH Zip: 44114 D. Business Telephone Number: 2 �_(�g--� QA(i'L E. Business Fax Number: q1 b /) F. E-Mail Address: Zip: 46601 G. Maximum Number of Vehicles that can be parked at facility at one time: H. Total Number of Parking Spaces at facility: I. Hours during which vehicles may be stored: 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: J. Insurance Carrier and Amount of Li; State: State: M Zip: Insurance OR Bonding Agent and Amount of Bond: For Office Use Only Application Filed JAN 0 9 2017 public Works�A ov I Application Fee Paid Llcens' wee Paid JAN 0 9 2D17 Sent to Dept. JAN 0 9 2017 License Number 11-13109 Not Approved d°Ord of Public Works Reason 1 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 • : S :n11"I a�ra A. Applicant's Legal Nai B. Residential Address: City: C ( Cya Ao State: C W Zip: U_ C. Residential Telephone Number: D. Residential Fax Number: E. Cellphone Number: 2-0 to F. Position with Business: IV. OWNERSHIP A. Type of ownership (check 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: Residential Address: City: Telephone Number: 2. Partnership (List at least two (2) partners) Name #1: Residential Address: City: Telephone Number: Name #2: Residential Address: City:. Telephone Number: State: State: Zip: In State:' Zip: 3. Corporation Legal name of corporation: A Aj vi vI /f'���L Date and state of incorporation: _ / 7 k 2 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 IV. OWNERSHIP (Continued) A. Type of ownership (continued): 3. Corporation (continued) Resident Agent: Name: /47 r Title: -�� (, o BusinessAddress:_��_ City: I n'Yi State: Zip:,, Officers Name #1: Title: Business Address: City: Residential Address: City: Name #2: Title: Business Address: Citv: Residential Address: City: Name #3: Title: Business Address: Citv: Residential Address: City: 3 State: State: State: State: State: Zip: Zip: Zip: Zip: For all municipal business Ilcense questions, contact: City of South Bend • Department of Community Investment 227 West Jefferson Blvd • Suite 1400 5 -South Bend, Indlana 46601 •574.235.5912 • F: 574.235.9b21 LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION. - 4-39 _ I V. INCLUDE COMPLETE RATE AND HOUR SCHEDULE WITH APPLICATION 4) VI. INCLUDE A CURRENT INSURANCE POLICY OR BOND 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. �b, Signature Date ,.,..., MARYC-1 OP ID: KL s►�oszc� CERTIFICATE OF LIABILITY INSURANCE DA0110612017TE Y> 01/0612017 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 Oswald Companies 2000 Polaris Parkway P. O. BOX 728 Columbus OH 43216.0728 James B. bswald Company House CONTACT James B. Oswald Company HouNAME,se PxoxE 614-796-7728 Alc No •888-323-1383 AX No: EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA:Westfield Insurance Company 24112 INSURED Mary Coyne Investments LLC Coyne Investments LTD 1428 Hamilton Ave INSURER B: INSURER C: Cleveland, OH 44114 INSURER D: INSURER E: INSURERF: CERT!Fl:ATE ns•UMBER: REVISION NUMBER: V 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. LTR TYPE OF INSURANCE %DOLINSR INVD POLICYNUMBER MMI�UYEFF Y EXP MMIDDATY' LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE ❑X OCCUR CWPOS17747 0211412016 0211412017 PREMISES Ea oaunence $ 500r000 MFA EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY DjECT 1:1LOC $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea aeddenl $ 1,000,000 BODILY INJURY (Per person) $ A ANYAUTO CWPOS17747 02114/2016 02/1412017 BODILY INJURY (Per accident) $ ALLOWNED X SCHEDULED AUTOS AUTOS NON -OWNED X HIREDAUTOS X AUTOS Weracd.rd) E Per aceMent $ S A X UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE CWPO817747 02114/2016 02/14/2017 EACH OCCURRENCE $ 2,000,000 rl AGGREGATE $ 2,000,000 DEO I X I RETENTION$ 0 1$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERNECUTNE YIN W OFFICERIMEMBER EXCDEDT (Mandatory in NH) STATUTE ER E.L.EACHACCIDENT $ E.L. DISEASE -EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ Ityea, desadbe under DESCRIPTON OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be etlached it more apace Is required) RE: 214 W Wayne St, South Bend, IN 46601 117 S William St, South Bend, IN 46601 123 N Main St, South Bend, IN 46601 o un, nco r.ANCPI I GTION CITYSO- Ci of South Bend City SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 125 S Lafayette Blvd #100 ACCORDANCE WITH THE POLICY PROVISIONS. South Bend, IN 46601 AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORAI ION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD 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 •574.235.59127 :57744.235.9021W LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION - 4-39 I. APPLICATION TYPE Check One: New Renewal XXX II. BUSINESS DATA A. Business Name: MC Investments, LLC B. Business Address: 214-216 W. Wayne St.' City: South Bend State: IN Zip: 46601 C. Mailing Address (If different from above): 1428 Hamilton Ave. city: Cleveland State: OH Zip: 44114 D. Business Telephone Numbe�r:}}4��.4Z , E. Business Fax Ni f % F. E-Mail Address: Al H / � A P k1i 1 _ rfA-1 G. Maximum Number of Vehicles that can be parked at facility at one time: Lid H. Total Number of Parking Spaces at facility: I. Hours during which vehicles may be stored: H. Premises are (check one): Leased by Applicant Owned by Applicant If Leased: Owner's Name: Owner's Business Address: City: State: Zip: Owner's Residential Address: City: Stater Zip: J. Insurance Carrier and Amount �of� Liability Insurance OR Bonding Agent and Amount of Bond: /a %�'/d!/1't- / For Office e_" Application Filed JAN 0 9 2D�_ pp Application Fee Paid JWO 9 2017 License Fee Paid JAN 0 9 911117 Sent to Dept. JAN O 9 ZU17 License Number 17-773% Not Approved Reason 1