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HomeMy WebLinkAboutLicense - Renewal for Public Parking Facility - Episcopal Cathedral of St. JamesFor 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 I. APPLICATION TYPE Check One. New II. BUSINESS DATA Renewal $5.00 Public Portal A. Business Name: EPISCOPAL CATHEDRAL OF SAINT JAMES B. Business Address: 117 N. LAFAYETTE BLVD. City. SOUTH BEND State: IN C. Mailing Address (If different from above): City: State: Zip: Zip: 46601 D. Business Telephone Number: 574-2132-4837 E. Business Fax Number: F. E -Mail Address: OFF ICE@STJAMESSOUTHBEND.ORG G. Maximum Number of Vehicles that can be parked at facility at onetime: 25 H. Total Number of Parking Spaces atfacility: 25 I. Hours during which vehicles may be stored: OPEM 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: BALANCE DUE = $75.00 For Office Use Only Application Filed JANUARY 7, 2021 Public Works Approval Application Fee Paid JANUARY 7, 2021 License Fee Paid Sent to Dept. JANUARY 7, 2021 License Number PBP2021-001 Not Approved Reason 1 111 '&^ A ,, L. i [,v M I 1 fir, Lv- `v ( C C> -L- CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS ULL 4 Elizabeth A. Maradik, President Gary A. Gdot, Member I- l' l Josepb R. Molnar, Member Jordan V. Gathers, Member Member Anent: Anne Fuchs, Clerk 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: C. Residential Telephone Number: D. Residential Fax Number: E. Cellphone Number: F. Position with Business: L'I P IV. OWNERSHIP A. Type of ownership (check one): Sole Proprietorship (If sole proprietorship, proceed to 1). Partnership (If partnership, proceed to 2). xxx 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 ity:Telephone Number. Name #2: Residential Address: City: Telephone Number: State: State: p: Zip: Zip: 3. Corporation Legal name of corporation: EPISCOPAL CATHEDRAL OF ST. JAMES Date and state of incorporation: 1868 2 For all municipal business license questions, contact: City of South Bend • Department of Community Investment 227 West Jefferson Blvd • Suitc 1400 S •South Bend, Indiana 46G01 • 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: NANCY STUDEBAKER Title: ADMINISTRATIVE ASSISTANT TO THE DEAN Business Address: 117 N. LAFAYETTE BLVD. City. SOUTH BEND State: IN p: 46601 Officers: Name #1: CHRISTOPHER HILLAK Title: SR. WARDEN Business Address: 117 N. LAFAYETTE BLVD. City: SOUTH BEND State: IN Zip: 46601 Residential Address: City: State: Name #2: JANE HUNTER Title: JR. WARDEN Business Address: 117 N. LAFAYETTE BLVD. City: SOUTH BEND State: IN Residential Address. City State: Zip: lip: ip: 46601 Name #3: PEG SWADENER Title: TREASURER Business Address: 117 N. LAFAYETTE BLVD. City: SOUTH BEND State: IN Residential Address: City: _ State: Zip: p: 46601 3 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 CURRENT INSURANCE POLICY OR BOND VII. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION VIII. 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. JANUARY 7, 2021 ONLINE RENEWAL Signature 2021 PARKING RATES $25.00 PER MONTH DUE BY THE 1ST OF EACH MONTH AFTER FIVE DAYS A $5.00 LATE FEE IS CHARGED IF PAYMENT IS NOT RECEIVED AFTER THIRTY DAYS, THE PARKING PRIVILEGES ARE REVOKED Date Episcopal Cathedral of Saintjames 117 N Lafayette Blvd South Bend, Indiana 46601 D74 232 4837 Thursday, January 7, 2021 2021 Parking Rates The monthly fee is $25 and due in the office by the first of the month for the following month. After five days a $5 late fee will be charged . If payment is not received after thirty days, your parking privileges will be revoked. Fees may be paid by check or money order; and may be submitted by mail or brought to the office. SOUTHIND01 A�ORO CERTIFICATE OF LIABILITY INSURANCE DA 111212021 111212021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IIVII-UM IAN 1: IT the certiticate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed - If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CT JJ --8 —00 — The Church Insurance Agency Corp 1-293-3525 Y FAX 210 S out h St, Ste 2 SA1C. Ne E><t}; Bennington, VT 05201-2894 INSURED Cathedral of St James 117 N Lafayette Blvd South Bend, IN 46601-1507 INSURER AFFORDING COVERAGE Church Ins Co of Vermont I INSURER S; INSURER C : 10 RIRD: INSURER E - INSURER F NRIC p 110669V REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, _EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ITR SR i yTYPE OF INSURANCE DDL1$UBR POLICY NUMBER POLICY EFF POLICY EXP - LIMITS A I X J COMMERCIAL GENERAL LIABILITY FACHO999RRENCE_ $ 1,000,0C CLAIMS-MADEExi OCCUR N N P0006095 5/1/2020 5/1/2021 ETaRErir>=1i 1,000,00 P- 55.{Ea occurrenret S 30,00 - — r�RsQM�L &, Aov INJ�IFiY 1,000,00 P11W1LA:GGREGATE LIMIT APPLIES PER: ENERALAGGiiFr,GAFE S 5,000,00 POLICY ❑ PERCT O ❑ LOC r ............... _ ! I 1 nnn ITf1 AUTOMOBILE LIABILITY f PPMOINED SINGLE LIMIT a3.4IIfti1.. ANY AUTO -i$ Ill OWNED SCHEAUTOS AUTOS ONLY j +!f BOOlLYINJURY Per. -[ n S AUTOS ONLY 8 ALl OS�NEY f +I BOOlLYlNJ RY PBralxiden! I P,D_�FY � GE -- -- UMBRELLA LIABOCCUR J FACH - URREN� EXCESS LIAR CLAIMS -MADE + AGGREGATE S DED 71 RETENTION $ WORKERS COMPENSATION S AND EMPLOYERS' LIABILITY Y 1 N PA TE ,�* ANY pp��FIC£R/M MTBOER7PXCtUOEb%ECUTIVE I�1 N/A E-L-EACCHACCIDENT�_ [Mandatory�n NH} �I descrme under E_; DISEASE - EA EMPLOYEE S If s, DE IPTION FOP RAT! N I �v A General Liability - "S"form N N VPPDO06095 51112020 5/112021 Umbrella Cove age I DESCRIPTION OF OPERATIONS' LOCATIONS? VE[ IICLES (ACORD 101. Additional Remarks Schedule, may ne attached if more space is required) Church parking lot used as public facility, city named as an additional insured. 117 N Lafayette Blvd. public parking 309 W Washington publick parking 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 - TION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of South Bend THE EXPIRAIION DATE THEREOF, NOTICE WILL BE DELIVERED IN 227 W Jefferson Blvd., Ste 1400 South ACCORDANCE WITH THE POLICY PROVISIONS - South Bend, IN 46601 - AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD