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HomeMy WebLinkAboutLicense - Renewal for Public Parking Facility - Episcopal Cathedral of St. James1316 COUNTY -CITY BUILDING 227 W. JEFFERSON BOULEVARD SOUTH BEND, INDIANA 46601-1830 PHONE 574/235-9251 FAx 574/235-9171 CITY OF SOUTH BEND JAMES MUELLER, MAYOR BOARD OF PUBLIC WORKS February 13, 2024 Mr. Steven Mast Episcopal Cathedral of Saint James 117 N. Lafayette Blvd. South Bend, IN 46601 financegstj amessouthbend. org RE: Renewal of Public Parking Facility License Dear Mr. Mast: At its February 13, 2024 meeting, the Board of Public Works approved the above referenced public parking facility license renewal. If you have any further questions, please call this office at (574) 235-9251. Sincerely, Is/ Theresa Heffner Theresa Heffner, Clerk Enclosures TH/lh ELIZABETH A. MARADIK JOSEPH R. MOLNAR GARY A. GILOT MURRAY L. MILLER BRIANA N. MIcou 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 I. APPLICATION TYPE Check One: New Renewal V II. BUSINESS DATA 1 g ( c A. Business Name:+ k4-0.Y B. Business Address: f f 71 �J ko,-EVC64 v& City: �0J _R K4_ State:_--t-1'd Zip: c'u (� C. Mailing Address (If different from above): Citv: State: Zip: D. Business Telephone Number: 6,71-f- 2 -3 1=�:o -3,% E. Business Fax Number: r F. E-Mail Address:h6LiC>e G. Maximum Number of Vehicles that can be parked at facility at onetime: Inki H. Total Number of Parking Spaces at facility: I. Hours during which vehicles may be stored: H. Premises are (check one): Leased by Applicant t Owned by Applicant X, If Leased: Owner's Name: Owner's Business Address: City: Owner's Residential Address: Zip: City: State: ZIP; J. Insurance Carrier and Amount of Liability Insurance OR Bonding Agent and Amount of Bond: For Office Use Only Application Filed J AN 1 12024 Public Works Approval Application Fee Paid JAN I I < License Fee Paid Sent to Dept. 1 d N 1 1 2094 License Number 6 1109, 4 - 07 CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS ;aJ w, �' y F.li ,be[h A. Me dik, President Joseph R. Molnar, Vice President ` Gfa • Gary A. Gilol, Member Bdi Mic , Member Mormy E. Miller, Member Attest Theresa M. Heffner, Clerk Dz . February 13, 2024 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: St-cvo\ M.&SA 1l C e. B. Residential Address: P b, City: 1A.t L aI `(5 `e State: Zip: C. Residential Telephone Number: D. Residential Fax Number: E. Cellphone Number: 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: State: lip: Telephone Number: 2. Partnership (List at least two (2) partners) Name #1: Residential Address: City: State: Zip: Telephone Number: Name #2: Residential Address: City: State: Zip: Telephone Number: 3. Corporation _ [� A Legal name of corporation: i �rC�+ R—��� r ��e Date and state of incorporation:�- 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: qq6 Title: Business Address: t� ail City: S U �" State: I- I" Zip: Officers: Name #1: 1__ ft2a.bt+V go Ir 1y-eLit Title: 5 r` ) &r ALAA' Business Address: City: State: Zip: Residential Address: City: State: Zip: a-vi Name #2: Title: Y W Business Address. City: State: Zip: Residential Address: City: State: Zip: Name #3: Title: Business Address: City: State: Zip: Residential Address: City: State: zip: M 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 - 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. )'n" -A",L Signature 4 Date SOUTHIND01 CAMP CERTIFICATE OF LIABILITY INSURANCE DA51„12023 `' 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 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 JgWCT LeeAnn Campantello The Church Insurance Agency Corp ,tC, No. Fxt : (800) 293-3525 Ftx, Na): 210 South St, Ste 2 Fd�"DEs . campaniecpg.org A Bennington, VT 05201-2894 _ INSURERS AFFORDING COVERAGE NAIC # , 0 A .Church Ins Co of Vermont 110669V INSURED Cathedral of St James INSURER B 117 N Lafayette Blvd INSURER C : South Bend, IN 46601-1507 INSURER D : _ I INSURER E: INSURER F o LZUICInki All IARMr.: p• 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 TYPE OF INSURANCE ADDL IiUBR so v4vD POLICY NUMBER I POLICY EFF LTR POLICY EXP LIMITS A I X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS -MADE OCCUR N N VPP0006095 5/1/2023 511/2024 DAMAGE RENTED S 1�000�QQQ 30,000 MED EXP (Any one person, 1,000,000 PERSONAL, & ADV INJURY S 5,000,000 GEIVLAGGREGATE L�IMpIT� APPLIES PER: GENERAL AGGREGATE S HPOLICY ❑ JELOC PRODUCTS - COMP/OP AGG : $ 1,000,000 pOT OTHER S INED NGLE1.IM1T _C[E �Ai S AUTOMOBILE LIABILITY 9_4enD S ANY AUTO BODILY INJURY Perperson) OWNED F SCHEDULED AUTOS ONLY AUTOSpS BODILY I�N'yJURY Per accident S AUTO$ &,5 0!rD R accida 114GE ONLY I I EACH OCCURRENCE S UMBRELLA LIAR HOCCUR I EXCESS LIAB CLAIMS -MADE I AGGREGATE iI I S S DED RETENTIONS WORKERS COMPENSATION l PER STATIT OTH- ER 1 AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH A CIDENT S OFFICER/MEMBER EXCLUDED? NIA ❑ { Mandatory in NH _ E.L. DISEASE - EA EMPLOYE Is If yes, describe under DFSC IPTI N QF OPERATJONS below - I Ol - POLICY IMIT A General Liability - "S" Form N N 'VPP0006095 511/2023 5/112024 Umbrella 4,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (ACORD 101, Ad(wuriol Remarks Schedule, maybe 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 '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 IPROVISIONS OR REQUIRED BY LAW. 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 (2016/03) ©1983-2015 ACUKU CUKPUKA I IUN. Au rlgncs reservea. The ACORD name and logo are registered marks of ACORD