HomeMy WebLinkAboutPublic Parking Facility - Episcopal Cathedral of St JamesTO:
FROM:
SUBJECT
INTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT:
om Anderson, Code Enforcement
ederico Rodriguez, Fire Department
Matt Longfellow, Engineering
Matt
Dressel, Community Investment
1`�arry Magliozzi, Area Plan
Angela Smith, Area Plan
Linda M. Martin, Clerk
2/22/2018
License Application for Public Parking Facility -Renewal
LOCATION: Episcopal Cathedral of St. James
117 N. Lafayette Blvd
DATE DUE: March 6, 2018
FAX OR E-MAIL TO:
235-9171 1 lmartin@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 - 574.235.5 1 2-F:574.235.9021
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LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
I. APPLICATION TYPE Check One:
11, BUSINESS DATA
k =_
A. Business Name: EPISCOPAL CATHEDRAL OF ST. JAMES
B. Business Address: 117 N. LAFAYETTE BLVD.
City: SOUTH BEND State: IN
C. Mailing Address (If different from above):
City: — State:
�D. Business Telephone Number: 574-232-4837
E. Business Fax Number:
F. E-Mail Address: OFFICE@STJAMESSOUTHBE,ND.ORG
Renewal XXX
12
G. Maximum Number of Vehicles that can be parked at facility at one time: 09
H. Total Number of Parking Spaces at facility: 25
I. Hours during which vehicles may be stored: OPEN
H. Premises are (check one): Leased by'Applicant Owned by Applicant X
If Leased:
Owner's Name:
Owner's Business Address,:
City: State: Zip:
Owner's Residential Address:
City: State: Zip:
J. Insurance Carrier and Amount of Liability Insurance OR Bonding Agent and Amount of Bond:
_VA... NA\�rdl 1'461 �Y-M.IAC,&Rfi V\A 1) rKK Q, OF' W Y-M 0 Y\-
For Office Use Only
Application Filed FEB 0 1 2018 Public Works Approval
Application Fee paid: FEB 0 12018 License Fee Paid
Sent to Dept. FEB 0 1 L?Q18 License Dumber
43"mr#J 01 flublic, Vo;,ka
Not Approved
Reason
Ili
For all municipal business license questions, contact: City of South Bend a Department of Community Investment
227 West Jefferson Blvd • Suite 14005 -South Bend, Indiana 46601 •574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION W 4-39
III. PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Celephone Number:
F. Position with Business:
State:
Zip:
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:.
State:
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Telephone Number:
Name #2:
Residential Address:
City:
Telephone Number:.
State:
State:
3, Corporation
Legal name of corporation:
Date and state of incorporation:
F1
Zip:
Zip:
Zip:
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 14005 -South Bend, Indiana 46601 e 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: �y
Name: 5i-.1fco Ak
Title: A--:,5 f5s f a'y�
Business Address: Q'7
City: 66 U +A& &V. "
Officers:
Name #1:
Title:
Business Address: _
City:
Residential Address:
City:
CLS V
State:
.1 Qy, (L��(��Wd.e_1
State:
Name #2: J O`Ve- U—(j t'k4- '
State:
zip;
Zip:
N
Title: MY-
Business Address: (see ado o vf,-)
City: State: Zip:
Residential Address:
City: State: Zip:
Name #3: l i WA I&Y U4-0 d—
Title: f rt V'_S f
Business Address: e-e- o-(b E) V-
City: State: Zip:
Residential Address:
City: State: Zip:
A44-V
3
For all municipal business license questions, contact: City of 5outh Bend + Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 + 574.235,5912 + r: 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
VIII. AFFIRMATION
1
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
11
l
1 It
Date?
VRon
COMPANY Of VL MONT CERTIFICATE OF INSURANCE
The Church Insurance Company of Vermont February 14, 2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Insurer providing coverage: The Church Insurance Company of Vermont
PRODUCER:
The Church Insurance Company of Vermont
210 South Street
Bennington, Vermont 05201--5000
INSURED:
Cathedral of St James
1 17 N Lafayette Boulevard
South Bend, IN 46601
MORTGAGEE ----
L
OSS PAYEE ----
EMAIL: CICVTcerts@cpg.org
FAX: 802-753-1385
CERTIFICATE HOLDER:
CITY OF SOUTH BEND
227 WJEFFERSON BLVD #1400
SOUTH BEND, IN 46601
ADDITIONAL INSURED
The policies of insurance listed below have been issued for 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, aggregate limits
shown may have been reduced by paid claims.
POLICY NUMBER: VPP0006095 CERTIFICATE EFFECTIVE DATE: 5/1 /2017 EXPIRATION DATE: 5/1/2018
Commercial General Liabilitv
Occurrence Forun
General Aggregate applies per policy: Limits
EACH OCCURRENCE/AGGREGATE $1,000,000 Occ/5,000,000 Agg
FIRE DAMAGE (ANY ONE FIRE) $ 1,000,000
MEDICAL EXPENSE (ANY ONE PERSON) $ 30,000
Directors' & Officers' Liabilitv $1,000,000
Employment Practices Liability $1,000,000
Commercial Property
LOCATION: 11 1-1 1 7 N Lafayette Blvd South Bend; IN 46601
COVERAGE INFORMATION: BLANKET BUILDING AND CONTENTS, REPLACEMENT COST, SPECIAL FORM, THEFT INCLUDED
BLANKET BUILDING & CONTENTS LIMIT: $1 1 368200
PROPERTY DEDUCTIBLE: $1,000
FLOOD DEDUCTIBLE: 2%
OTHER REMARKS: THE CITY OF SOUTH BEND IS AN ADDITIONAL INSURED ON THE GL FORM 0717 10 05 WITH REPSECT TO
THEIR STATUS AS THE LESSOR OF THE PARKING SPACES AT 309 W WASHINGTON ST, SOUTH BEND, IN 46601
DISCLAIMER: The Certificate of Insurance does not constitute a contract between the issuing insurer, authorized representative,
and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policy
listed thereon.
CANCELLATION: THE POLICY IS SUBJECT TO THE PREMIUMS, FORMS, AND RULES IN EFFECT FOR EACH POLICY PERIOD. SHOULD THE POLICY
BE TERMINATED, THE COMPANY WILL ENDEAVOR TO GIVE THE ADDITIONAL INTEREST IDENTIFIED 30 DAYS WRITTEN NOTICE, AND WILL
SEND NOTIFICATION OF ANY CHANGES TO THE POLICY THAT WOULD EFFECT THAT INTEREST, IN ACCORDANCE WITH THE POLICY
PROVISIONS OR REQUIRED BY LAW.
AUTHORIZED REPRESENTATIVE
STEVE FOLLOS