Committee on Zoning, Landmarks, and Building Standards
(Signs)
ORDERED, That the Commissioner of Buildings is hereby directed to issue a sign permit to: (Contractor's name and address)
Sign-Q-Rama
6229 West Roosevelt Road
Chicago. Illinois 60402
for the erection of a sign/signboard over 24 feet in height and/or over 100 square feet (in area
of one face) at: (Business Name & Address)
New Sparks Auto Parts
1734 West 47th Street
Chicago. Illinois 60609
Dimensions: Length 15'-0" Height 12'-0»
Height above grade/roof to top of sign 12'-0"
TOTAL SQUARE FOOT AREA: 180 square feet
Alderman, 15th Ward
Such sign(s) shall comply with all applicable provisions of TITLE 17 of the Chicago Zoning Ordinance and all other applicable provisions of the Municipal Code of the City of Chicago governing the construction and maintenance of outdoor signs, signboards and structures.
.V;
PUBLIC WAY USE UNIT: PERMIT INFORMATION SHEET
08/16/2013 - LisaPusatcri
DBA Name
Location
Zip Code
Account Number
Site Number
Area
Permit Type Permit Number
NEW SPARK ALTO PARTS
1734 W. 47TH ST.
60609
310298
I
peTESht
BANNER % 1106143
Next steps: Department of Buildings - Permit process for signs
Your Public Way Use permit number is shown above. This number is to be used for each item on your DOB application and is needed for the Buildings (DOB) online sign application located @ www.cityofchicago.org/buildings. All signs, canopies, banners, marquees and awnings require a buildings permit. Only a licensed sign erector may apply for the Buildings permit online. The Buildings permit application will ask for the Public Way Use permit number supplied above. For additional information please contact the Buildings Department at (312) 744-3400.
Please return the completed Public Way Use application to City Hall - 121 N. LaSalle Street, Chicago, IL 60602 Room 800. The completed application package must include a copy of the completed DOB application and the Public Way Use application. The Public Way Use application must contain the Alderman's signature, site plans on 8 1/2 X 11 paper, photos of the item(s), the signed Acceptance letter and a copy of the insurance certificate. For additional information please contact BACP at (312)-74-GOBIZ (312-744-6249).
APPlJCATION TO USE THE PUBLIC RIGHT OF WAY
APPLICANT INFORMATION ^ a MJ" ~ - f ^ ^ ^
LEGAL NAME OF ENTITY /yfeW;:-^S^rL'rt^l^^ " .
PERMIT MAILING ADDRESS:
CITY: / £ g £3 STATE £^L ZIP CODE todtoG*)
CONTACT PERSON U/^T/Yl^rx A^.b/VTITLE Qpfr-vg-cf"
phone-7?^ ;z<r7(c-lIlia fax773 9£7'7j/£> E-MAIL S^>r^>V^At6^t USE OF THE PUBLIC Vflff
1. List the proposed cr existing use Selow and complete the worksheet on cage 3 Use only one application per public way use type
TYPE HOW MANY? BUILDING ADDRESS
2. Please enclose one sketch of proposed use of the public way, which maps to scale the proposed use and its relationship to surrounding right-of-way All measurements must be indicated
The prints should also accurately depict trie location of the oroperty line and public facilities (meters, light poles, sidewalks).
V
APPLICANT CERTIFICATION
I hereby certify that all statements made as part of the application, and the attachments herein, are true to the best of my knowledge and belief.
BY
^QlU.ifC) L~0'j>Q?-- TITLE:
F.E.I N. or SOCIAL SECURITY NUMBER: I
ALDERMAN'S APPROVAL
As part of this application process, you are required to notify/°Dlain approval from the Alderman in whose ward your proposed use of the public way is located
ALDERMAN'S SIGNATURE WARD DATE
-* JUJ City of Chicago i Department of Business Affairs and Consumer Protection ; Public Way Use Unit jswsAfHUM* Business Assistance Center | City Hall. Room 800 121 North LaSalle Street I Chicago, Illinois 606u^ coNswtfinoTKWw www.t'ityofchicago.org/bacp I 312.74.GOBIZ i744.6249) j 312.742 1974 (TTY)
Page 2 of 4
CITY Of- CHICAGO BACP-PWU ■ BUNDLE PERMIT APPLICATION ■ V 0=7:8.10
APPLICATION CHECKLIST (continued)
□ Acceptance Letter
ACCEPTANCE OF GRANT OF PRIVILEGE PERMIT TERMS
I hereby understand and accept the terms and conditions relative to the issuance of the permit, and by signing below, I acknowledge the receipt of a copy of the Municipal Code of Chicago's 10-28 and » 13-20 regulations, as well as all the additional requirements rromulgateC herein:
i understate it Stiail be rr.y au?V as the permit holder, and as a condition of tne permi:. :o.
- Comply with all th«r requirements defined w\br, '.".Visage's :/unicraal Cede, the Rules and Regulations, as weS as :he requirements promulgated herein;
- Upon the passage of the pt,-mil ordinance at G''v C;-'j-v!. oay th*:- non-refunoarile applicable Grant ol Pnvi'ege annua! p .tt it fee .
3 Upon the submission o< fr.e peirat 3ppiicav.rjr. [nz applicant shall fjmisn the certificate o' nsurance; and.
4 Resolve ail Account Holds since failure to co so will prevent the processing of this perm:! application;
5. Install or maintain the grant ol p-ivilege after the issuance of 'he cemit hy 'he Commissioner of Business Affairs and Consumer Protection
- I hereby agree to accept the terms and conditions relative ic issuance of the permit.
- i agree to renew the Certificate of Insurance at leas' tC days prior -o expiration of the policy
- I understand that :f (he i'.errt or items are not constructed/rnatntainel the permit 'ees will not be refunded.
I understand that failure to adhere to all conditions imposed in. the permit may result in revocation of the permit.
SIGNATURE
' PRiNT NAME yi. ft U. < iO ■O "p <J ~~L~-
F.E.I.N or SOCIAL SECURITY NUMBEF,
DATE. jA-^;c^|3.
title- \tcD \s> n ntACTJA
J
"E.RMIT TYPE:
ACCOUNT # i /
LEGAL NAME OfEnVl^-^^ fry \ f & L^pt-'^ BUSINESS NAVF (DBA). -Tl A /tV i f*6 *--b £ \±~:
'STATE: Illinois
BUSINESS LOCATION ADDRESS' irv Chicago QttjSt^fr'
BUSINESS PHONE 1 *\ 3 YlLf ■ Ij 3^
s
6 B-V\ji^~jr) Department of Business Affairs and Consumer Protection IBACPl 8usiness~Assistance Center (BACt
Pubiic Way Use Unit (PWU) ■ Citv Haft. Rocm SOO i?l Norrh LaSalle Street, Chicago, Illinois 6060?. SgESJSgg&Ji WWW.Cltyofchtr.aso.0r3/bacp ■ 31274 GOBI! '44.624-)) >. v ,'4:. '974 ,-Tivi
CITY OF CHICAGO ■ BACP-PWU ■ BUNDLE PERMIT APPLICATION V. 12.21.12
APPLICATION TO USE THE PUBLIC RIGHT OF WAY
APPLICATION WORKSHEET
* For use by NEW APPLICANTS ONLY.
a For renewals obtain form from City Hall, 121 N. LaSalle St., Rm. 800 or call (312) 74 - GOBIZ (744-6249)
Complete the worksheet for each use of the public way and indicate all applicable measurements
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Exact Street (i.e. S. State St.) |
Quantity |
Length of structure along public way |
Height of structure |
Depth of structure |
Height above grade Total depth over public way |
Is this sign(s) Illuminated? (Y/N) |
Is this an Existing Public Way Use (Y/N) |
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1Committee on Zoning, Landmarks, and Building Standards (Signs) ORDERED, That the Commissioner of Buildings is hereby directed to issue a sign permit to: (Contractor's name and address) Sign-Q-Rama 6229 West Roosevelt Road Chicago. Illinois 60402 for the erection of a sign/signboard over 24 feet in height and/or over 100 square feet (in area of one face) at: (Business Name & Address) New Sparks Auto Parts 1734 West 47th Street Chicago. Illinois 60609 Dimensions: Length 15'-0" Height 12'-0» Height above grade/roof to top of sign 12'-0" TOTAL SQUARE FOOT AREA: 180 square feet Alderman, 15th Ward Such sign(s) shall comply with all applicable provisions of TITLE 17 of the Chicago Zoning Ordinance and all other applicable provisions of the Municipal Code of the City of Chicago governing the construction and maintenance of outdoor signs, signboards and structures. .V; PUBLIC WAY USE UNIT: PERMIT INFORMATION SHEET 08/16/2013 - LisaPusatcri DBA Name Location Zip Code Account Number Site Number Area Permit Type Permit Number NEW SPARK ALTO PARTS 1734 W. 47TH ST. 60609 310298 I peTESht BANNER % 1106143 Next steps: Department of Buildings - Permit process for signs Your Public Way Use permit number is shown above. This number is to be used for each item on your DOB application and is needed for the Buildings (DOB) online sign application located @ www.cityofchicago.org/buildings. All signs, canopies, banners, marquees and awnings require a buildings permit. Only a licensed sign erector may apply for the Buildings permit online. The Buildings permit application will ask for the Public Way Use permit number supplied above. For additional information please contact the Buildings Department at (312) 744-3400. Please return the completed Public Way Use application to City Hall - 121 N. LaSalle Street, Chicago, IL 60602 Room 800. The completed application package must include a copy of the completed DOB application and the Public Way Use application. The Public Way Use application must contain the Alderman's signature, site plans on 8 1/2 X 11 paper, photos of the item(s), the signed Acceptance letter and a copy of the insurance certificate. For additional information please contact BACP at (312)-74-GOBIZ (312-744-6249). APPlJCATION TO USE THE PUBLIC RIGHT OF WAY APPLICANT INFORMATION ^ a MJ" ~ - f ^ ^ ^ LEGAL NAME OF ENTITY /yfeW;:-^S^rL'rt^l^^ " . PERMIT MAILING ADDRESS: CITY: / £ g £3 STATE £^L ZIP CODE todtoG*) CONTACT PERSON U/^T/Yl^rx A^.b/VTITLE Qpfr-vg-cf" phone-7?^ ;z<r7(c-lIlia fax773 9£7'7j/£> E-MAIL S^>r^>V^At6^t USE OF THE PUBLIC Vflff 1. List the proposed cr existing use Selow and complete the worksheet on cage 3 Use only one application per public way use type TYPE HOW MANY? BUILDING ADDRESS 2. Please enclose one sketch of proposed use of the public way, which maps to scale the proposed use and its relationship to surrounding right-of-way All measurements must be indicated The prints should also accurately depict trie location of the oroperty line and public facilities (meters, light poles, sidewalks). V APPLICANT CERTIFICATION I hereby certify that all statements made as part of the application, and the attachments herein, are true to the best of my knowledge and belief. BY ^QlU.ifC) L~0'j>Q?-- TITLE: F.E.I N. or SOCIAL SECURITY NUMBER: I ALDERMAN'S APPROVAL As part of this application process, you are required to notify/°Dlain approval from the Alderman in whose ward your proposed use of the public way is located ALDERMAN'S SIGNATURE WARD DATE -* JUJ City of Chicago i Department of Business Affairs and Consumer Protection ; Public Way Use Unit jswsAfHUM* Business Assistance Center | City Hall. Room 800 121 North LaSalle Street I Chicago, Illinois 606u^ coNswtfinoTKWw www.t'ityofchicago.org/bacp I 312.74.GOBIZ i744.6249) j 312.742 1974 (TTY) Page 2 of 4 CITY Of- CHICAGO BACP-PWU ■ BUNDLE PERMIT APPLICATION ■ V 0=7:8.10 APPLICATION CHECKLIST (continued) □ Acceptance Letter ACCEPTANCE OF GRANT OF PRIVILEGE PERMIT TERMS I hereby understand and accept the terms and conditions relative to the issuance of the permit, and by signing below, I acknowledge the receipt of a copy of the Municipal Code of Chicago's 10-28 and » 13-20 regulations, as well as all the additional requirements rromulgateC herein: i understate it Stiail be rr.y au?V as the permit holder, and as a condition of tne permi:. :o.
- Comply with all th«r requirements defined w\br, '.".Visage's :/unicraal Cede, the Rules and Regulations, as weS as :he requirements promulgated herein;
- Upon the passage of the pt,-mil ordinance at G''v C;-'j-v!. oay th*:- non-refunoarile applicable Grant ol Pnvi'ege annua! p .tt it fee .
3 Upon the submission o< fr.e peirat 3ppiicav.rjr. [nz applicant shall fjmisn the certificate o' nsurance; and. 4 Resolve ail Account Holds since failure to co so will prevent the processing of this perm:! application; 5. Install or maintain the grant ol p-ivilege after the issuance of 'he cemit hy 'he Commissioner of Business Affairs and Consumer Protection
- I hereby agree to accept the terms and conditions relative ic issuance of the permit.
- i agree to renew the Certificate of Insurance at leas' tC days prior -o expiration of the policy
- I understand that :f (he i'.errt or items are not constructed/rnatntainel the permit 'ees will not be refunded.
I understand that failure to adhere to all conditions imposed in. the permit may result in revocation of the permit. SIGNATURE ' PRiNT NAME yi. ft U. < iO ■O "p <J ~~L~- F.E.I.N or SOCIAL SECURITY NUMBEF, DATE. jA-^;c^|3. title- \tcD \s> n ntACTJA J "E.RMIT TYPE: ACCOUNT # i / LEGAL NAME OfEnVl^-^^ fry \ f & L^pt-'^ BUSINESS NAVF (DBA). -Tl A /tV i f*6 *--b £ \±~: 'STATE: Illinois BUSINESS LOCATION ADDRESS' irv Chicago QttjSt^fr' BUSINESS PHONE 1 *\ 3 YlLf ■ Ij 3^ s 6 B-V\ji^~jr) Department of Business Affairs and Consumer Protection IBACPl 8usiness~Assistance Center (BACt Pubiic Way Use Unit (PWU) ■ Citv Haft. Rocm SOO i?l Norrh LaSalle Street, Chicago, Illinois 6060?. SgESJSgg&Ji WWW.Cltyofchtr.aso.0r3/bacp ■ 31274 GOBI! '44.624-)) >. v ,'4:. '974 ,-Tivi CITY OF CHICAGO ■ BACP-PWU ■ BUNDLE PERMIT APPLICATION V. 12.21.12 APPLICATION TO USE THE PUBLIC RIGHT OF WAY APPLICATION WORKSHEET * For use by NEW APPLICANTS ONLY. a For renewals obtain form from City Hall, 121 N. LaSalle St., Rm. 800 or call (312) 74 - GOBIZ (744-6249) Complete the worksheet for each use of the public way and indicate all applicable measurements Exact Street (i.e. S. State St.)QuantityLength of structure along public wayHeight of structureDepth of structureHeight above grade Total depth over public wayIs this sign(s) Illuminated? (Y/N)Is this an Existing Public Way Use (Y/N)I SIGNS/A'X"X i i - -
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1Committee on Zoning, Landmarks, and Building Standards (Signs) ORDERED, That the Commissioner of Buildings is hereby directed to issue a sign permit to: (Contractor's name and address) Sign-Q-Rama 6229 West Roosevelt Road Chicago. Illinois 60402 for the erection of a sign/signboard over 24 feet in height and/or over 100 square feet (in area of one face) at: (Business Name & Address) New Sparks Auto Parts 1734 West 47th Street Chicago. Illinois 60609 Dimensions: Length 15'-0" Height 12'-0» Height above grade/roof to top of sign 12'-0" TOTAL SQUARE FOOT AREA: 180 square feet Alderman, 15th Ward Such sign(s) shall comply with all applicable provisions of TITLE 17 of the Chicago Zoning Ordinance and all other applicable provisions of the Municipal Code of the City of Chicago governing the construction and maintenance of outdoor signs, signboards and structures. .V; PUBLIC WAY USE UNIT: PERMIT INFORMATION SHEET 08/16/2013 - LisaPusatcri DBA Name Location Zip Code Account Number Site Number Area Permit Type Permit Number NEW SPARK ALTO PARTS 1734 W. 47TH ST. 60609 310298 I peTESht BANNER % 1106143 Next steps: Department of Buildings - Permit process for signs Your Public Way Use permit number is shown above. This number is to be used for each item on your DOB application and is needed for the Buildings (DOB) online sign application located @ www.cityofchicago.org/buildings. All signs, canopies, banners, marquees and awnings require a buildings permit. Only a licensed sign erector may apply for the Buildings permit online. The Buildings permit application will ask for the Public Way Use permit number supplied above. For additional information please contact the Buildings Department at (312) 744-3400. Please return the completed Public Way Use application to City Hall - 121 N. LaSalle Street, Chicago, IL 60602 Room 800. The completed application package must include a copy of the completed DOB application and the Public Way Use application. The Public Way Use application must contain the Alderman's signature, site plans on 8 1/2 X 11 paper, photos of the item(s), the signed Acceptance letter and a copy of the insurance certificate. For additional information please contact BACP at (312)-74-GOBIZ (312-744-6249). APPlJCATION TO USE THE PUBLIC RIGHT OF WAY APPLICANT INFORMATION ^ a MJ" ~ - f ^ ^ ^ LEGAL NAME OF ENTITY /yfeW;:-^S^rL'rt^l^^ " . PERMIT MAILING ADDRESS: CITY: / £ g £3 STATE £^L ZIP CODE todtoG*) CONTACT PERSON U/^T/Yl^rx A^.b/VTITLE Qpfr-vg-cf" phone-7?^ ;z<r7(c-lIlia fax773 9£7'7j/£> E-MAIL S^>r^>V^At6^t USE OF THE PUBLIC Vflff 1. List the proposed cr existing use Selow and complete the worksheet on cage 3 Use only one application per public way use type TYPE HOW MANY? BUILDING ADDRESS 2. Please enclose one sketch of proposed use of the public way, which maps to scale the proposed use and its relationship to surrounding right-of-way All measurements must be indicated The prints should also accurately depict trie location of the oroperty line and public facilities (meters, light poles, sidewalks). V APPLICANT CERTIFICATION I hereby certify that all statements made as part of the application, and the attachments herein, are true to the best of my knowledge and belief. BY ^QlU.ifC) L~0'j>Q?-- TITLE: F.E.I N. or SOCIAL SECURITY NUMBER: I ALDERMAN'S APPROVAL As part of this application process, you are required to notify/°Dlain approval from the Alderman in whose ward your proposed use of the public way is located ALDERMAN'S SIGNATURE WARD DATE -* JUJ City of Chicago i Department of Business Affairs and Consumer Protection ; Public Way Use Unit jswsAfHUM* Business Assistance Center | City Hall. Room 800 121 North LaSalle Street I Chicago, Illinois 606u^ coNswtfinoTKWw www.t'ityofchicago.org/bacp I 312.74.GOBIZ i744.6249) j 312.742 1974 (TTY) Page 2 of 4 CITY Of- CHICAGO BACP-PWU ■ BUNDLE PERMIT APPLICATION ■ V 0=7:8.10 APPLICATION CHECKLIST (continued) □ Acceptance Letter ACCEPTANCE OF GRANT OF PRIVILEGE PERMIT TERMS I hereby understand and accept the terms and conditions relative to the issuance of the permit, and by signing below, I acknowledge the receipt of a copy of the Municipal Code of Chicago's 10-28 and » 13-20 regulations, as well as all the additional requirements rromulgateC herein: i understate it Stiail be rr.y au?V as the permit holder, and as a condition of tne permi:. :o.
- Comply with all th«r requirements defined w\br, '.".Visage's :/unicraal Cede, the Rules and Regulations, as weS as :he requirements promulgated herein;
- Upon the passage of the pt,-mil ordinance at G''v C;-'j-v!. oay th*:- non-refunoarile applicable Grant ol Pnvi'ege annua! p .tt it fee .
3 Upon the submission o< fr.e peirat 3ppiicav.rjr. [nz applicant shall fjmisn the certificate o' nsurance; and. 4 Resolve ail Account Holds since failure to co so will prevent the processing of this perm:! application; 5. Install or maintain the grant ol p-ivilege after the issuance of 'he cemit hy 'he Commissioner of Business Affairs and Consumer Protection
- I hereby agree to accept the terms and conditions relative ic issuance of the permit.
- i agree to renew the Certificate of Insurance at leas' tC days prior -o expiration of the policy
- I understand that :f (he i'.errt or items are not constructed/rnatntainel the permit 'ees will not be refunded.
I understand that failure to adhere to all conditions imposed in. the permit may result in revocation of the permit. SIGNATURE ' PRiNT NAME yi. ft U. < iO ■O "p <J ~~L~- F.E.I.N or SOCIAL SECURITY NUMBEF, DATE. jA-^;c^|3. title- \tcD \s> n ntACTJA J "E.RMIT TYPE: ACCOUNT # i / LEGAL NAME OfEnVl^-^^ fry \ f & L^pt-'^ BUSINESS NAVF (DBA). -Tl A /tV i f*6 *--b £ \±~: 'STATE: Illinois BUSINESS LOCATION ADDRESS' irv Chicago QttjSt^fr' BUSINESS PHONE 1 *\ 3 YlLf ■ Ij 3^ s 6 B-V\ji^~jr) Department of Business Affairs and Consumer Protection IBACPl 8usiness~Assistance Center (BACt Pubiic Way Use Unit (PWU) ■ Citv Haft. Rocm SOO i?l Norrh LaSalle Street, Chicago, Illinois 6060?. SgESJSgg&Ji WWW.Cltyofchtr.aso.0r3/bacp ■ 31274 GOBI! '44.624-)) >. v ,'4:. '974 ,-Tivi CITY OF CHICAGO ■ BACP-PWU ■ BUNDLE PERMIT APPLICATION V. 12.21.12 APPLICATION TO USE THE PUBLIC RIGHT OF WAY APPLICATION WORKSHEET * For use by NEW APPLICANTS ONLY. a For renewals obtain form from City Hall, 121 N. LaSalle St., Rm. 800 or call (312) 74 - GOBIZ (744-6249) Complete the worksheet for each use of the public way and indicate all applicable measurements Exact Street (i.e. S. State St.)QuantityLength of structure along public wayHeight of structureDepth of structureHeight above grade Total depth over public wayIs this sign(s) Illuminated? (Y/N)Is this an Existing Public Way Use (Y/N)I SIGNS/A'X"X i i - - -i " I || i |
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See example of required plans beginning on the next page
NOTE: Pursuant to section 2-154-030 of the Municipal Code of the City of Chicago the Corporation Counsel of the City of Chicago may require any such additional information from any applicant to achieve full disclosure relevant to the request for action by the City Council or other city agency. Pursuant to section 2-154-020 of the Municipal code of the City of Chicago any material change in the information required above must be provided by supplementing this statement at any time up to the time the City Council or any city agency takes action on the application.
1 >V*jjf>rlr'j) Department of Business Affairs and Consumer Protection (BACP) ■ Business Assistance Center (BAC) X^jA^dT Public Way Use Unit (PWU) ■ City Hall, Room 800 121 North LaSalle Street, Chicago, Illinois 60602 cwSwrOTKAwww.cityofchicago.org/bacp- 312.74.GOBIZ (744.6249) 312.742.1974 (TTY)
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CITY OF CHICAGO ■ BACP-PWU' BUNDLE PERMIT APPLICATION V.12.21.12
APPLICATION TO USE THE PUBLIC RIGHT OF WAY
EXAMPLE OF SIGN DRAWING
a:
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I ^^V/^TT^ Department of Business Affairs and Consumer Protection (BACP) ■ Business Assistance Center (BAC)
P^V. >f Public Way Use Unit (PWU) City Hall, Room 800 121 North LaSalle Street, Chicago, Illinois 60602
CITY OF CHICAGO
DEPARTMENT Of BUSINESS AFFAIRS & CONSUMER PROTECTION (BACP)
BUSINESS INFORMATION SHEET
.eiT. Wav Usr
Type of PRE-AppJication Business
Aflririy ^ new silr Change of u.30.">
--.-11,111;« Site* i
i.-''.:t v*;:: . cc- *nD psocf cr removal s seouiR'"
Business Entity Information
Type of Business
Legal Name of Business
tMU legal raor?" as:' appears tfi !r-
"Doing Business As" Name
uc.
Corpo:al>on Moo-PtoW ' .st N^Ot'd ^P
r 1. v
V 'iy v.* £"
A State of Illinois File Number is REQUIRED for r+il (Illinois and Non-Illinois based'!. Ps, LLPs. LLCs. Corporations, and Non-Profit Corps
c,,t _r ini__i_ en- * ! / 1 A Assig.-.ed byif* Minols Secretary of State at59 W. Washington St. Su te 1240,
State Of HHnOiS Fll«#=^y/V (JljWlSO or® ^c*^*l*. i^r^^res
A Federal Employer Identification Number (EIN) is REQUIRED for all business er/.iv,- types except for Sole Proprietorships.
Fmnlrwor Montlfiratinn « Assigned by the Internal Revenue Seivlee at 230 S. Dearborn St. (312! 56M91
An Account ID Number is REQUIRED for ALL business entity types that conduct business in the state of Illinois or with Illinois customers ;(ormenylBT#) IDOR Account ID #
Public Way Use (PWU) s.gr< aw-,-PWU Permit #
Assigned by the Illinois Department oFRevenue at liK w RandofchSl \HQZ) 732-8866. or @ hnp^tojiftH».gav/8ij^esses/irdexhw > 6jsiness Registraicn
.'anupv B.-:'i"0' 'J<rie*.ill' Cafe Othe'
PWU Account #
Business Activity and Location
Business Activity
If selling goods, what type of sale?" Retail (Consumers Only) Wholesale (Business to Business Only) Bolt)
Business Site Address \~\
Sttet Humberts; V'vf/VV Wit*
J,0 ?le '<Vj( S floor a
7'.?
Amount of employees at this site
Square footage used by the business
Primary Contact Person /L. |
cts' .Y3T*
■' *\.' W**r»?
Contact Phone # f /' ^
... r
t-
Contact E-mail Address
P( f^.Sfr' "OMPl.PTF THE BACH SID£ 0? THiS FORM AS WELL ■*
Owner and Officer Information (as required per 4-4-050)
Sole Proprietors are required Ic orovtfe information about fr-.e Individual who cw?s the business
Partnerships S Limited Partnerships are required to provide ir'ormakon about all the Partners a' the Mgsi'iza'jon
Limited Liability Companies are required ;o provide infornaoor about the organization's Members and ar» asier sharehoider(s) wfh a Paior benef cial niteres' Corporations are required to provide information about !h» oigar zabon s President. Secretary and any ot,lf*r shareholders) wit*", s beneficial nlsreM Non-Profit Corporations are recurred to picvnde information abou: tn? organization » President and Secretary
Proof of identification may be required to complete the actual application.
Ownership % Title
□ Sole Proprietor □ Partner □ President □ Managing Membe
7
Flrst-NaTTIes Middle Name
Current Residential Address .
r gather: \f {f^Q ,f| O Last Name _J
Suite/Apt.* City] ' State ZIP Code
Home Phone
-«:ILAddress,
^ociaj^^unty^uniber D_ato_of.Blrtri_
First Name
Last Name
iy-Ci-raniiei-Q_iiiiiiniyiliy"«n;Mli«r UI l^iner"
Middle Name
Suito'Apt. *
State ZIP Code
Current Residential Address
Home Phone
Email Address
Social Security Number Dale of Birth
Middle Name
Last Name
Ownership % Title
□ Vice President □ Member □ Other:
First Name
Suite/Apt. # Citv
State ZIP Code
Current Residential Address
Home Phone
Email Address
Social Security Number Date of Birth
Middle Name
Last Name
Ownership % Title
□ Treasurer □ Member □ Cther:
First Name
Suite/Apt * City
State ZIP Code
Current Residential Address
Home Phone
Email Address
Social Security Number Date of Birth
Middle Name
Last Name
Ownership % Title
□ Shareholder G Other
First Name
Suite/Apt. s City
State ZIP Code
Current Residential Address
Home Phone
Email Address
Social Security Number Date of Birth
Completed BIS forms may be submitted In-person at the address below, or by e-mail attachment at buMinessllceroe@cltyofchicaoo.ofg. Please do NOT include/send any payments with this pre-appllcatlon.
I HIIh1 CITY OF CHICAGO Department of Bvsirwss Affairs and Consumer Protection Business Assistance Center S-S«»i c'ty Hall 121 North LaSalle Street. Room Chicago, IL 60602 (312) 74-GOBIZ (744-6249) www.cltyofchicago.orp/bacp
DATE (MMTJC-YYYYl
10/23/13
CERTIFICATE OF LIABILITY INSURANCE op,d jt
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: H the certificate holder Is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed, tf SUBROGATION 15 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 endorsements).
LUIJIULI
Hunt Insurance Agency, Inc.
12000 S. Harlem Avenue
Palos Heights IL 60463-1153
Phone:708-361-5300 Fax:708-361-5316
name Lawrence K. Hunt, CIC, CRM
Twc.fNo.E«t« 708-361-5300""" 5/c.mq) 708-361-53K
NAIC
15261
INSURER l 'NSURER B INSURER C INSURER D INSURER G INSURER F
CUSTOMER ID » LOPEZ.-Z.
INSURERISl AFFORDING COVERAGE
Ramiro Lopez P.O. Box 32118 Chicago IL 60632
Society Insurance Company
REVISION NUMBER:
COVERAGES
CERTIFICATE NUMBER:
POLICY NUMBER
"■"! MIT'
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LTR
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■INSR | WVD!
TYPE OF INSURANCE
I
BOP 532215
: GENERAL LIABILITY
A ; ; -omw~^" a' -.fmiral jan.ir,
j """ \■ V , Va: F" J
!X' Business Owners
\ ... . .-.il M :
: POTTCY EFT POLICY EXF ~ jlMMlODfYYYYl (MM'DD'YYYYi
12/20/12 12/20/13
.1000000 ' f100000 $ 5000
2 2000000 i2000000
AUTOMOBILE LIABILITY
j am:,.
| ."US! .I ll :-■ j ...L," .■,.,-,
UMBRELLA LIAB "i EXCESS LIAB
i ■ "■ ' DHL* ■- IWU-
F-'L'I'.NKrf-. f
, WORKERS COMPENSATION AND EMPLOYERS' LIABILITY
a;-,y M-i.it■ i ;4:',i-^ai, :r-jcir 1-^.1 : nCEk'Ve.1!?:." _':_i|VFL (Mandaror> in NHi
310000
BUILDING
DESCRIPTION OF OPERATIONS ! LOCATIONS / VEHICLES (Attach ACORD 101. Additional Remarks Schedule rf more ?pece i» requrredl
City of Chicago, its agents and employees are listed as additional insured in regards to the banner located at 1734 W. 47th Street.
CANCELLATION
CERTIFICATE HOLDER
CHICT-2
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLIC > PROVISIONS
AUTHORIZED REPRESENTATIVE
ORATION. Ail rights reserved.
City of Chicago
Public Way Use Unit
121 N LaSalle - Room 800
Chicago IL 60602
ACORD 25 (2009/09)
The ACORD name and logo are registered marks of ACORD