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Temp. Use Permit - Chaka Stars FundraiserCity of Okeechobee 55 SE Third Avenue Okeechobee, FL 34974 (863) 763 -3372 Temporary Use Permit Permit Number: 16 -004 Permit Expiration: April 15, 2016 11:59PM Purpose of Request: Barbeque Fundraiser Property Owner: Karla Roby & Debra Sales Address: P.O. Box 1395 City: Okeechobee Date(s) of Event: April 15, 2016 8AM — 2:OOPM State: Florida Zip Code:34974 Applicant: Chaka Stars Applicant's Address: 1491 SW 86th Ave Phone Number: 706 - 305 -7613 Address of Project: 1600 S Parrott Avenue Current Zoning: Heavy Commercial (CHV FLU Designation: Commercial (C) Subdivision: 1st Addition to South Okeechobee Restrictions /Remarks: All debris must be removed upon final completion date. Owner understands and agrees to the following: X Issuance of a permit may be subject to other conditions and time limitations. X Issuance of a permit is not authorization to violate public or private restrictions. X Failure to comply with applicable regulations may result in withholding future permits. X There may be add' io . permits required from other governmental entities. gnature iL( .(.? . 4 AiL Geral Services Assistant REF: .ORD.716, Temporary Structures Date: /2 ip,/y/ April 12, 2016 Date CITY OF OKEECHOBEE General Services Department, Room 101 55 Southeast 3rd Avenue Okeechobee, FL 34974 Phone: 863- 763 -3372 ext. 218 Fax: 863 - 763 -1686 `LLB :9 : ; ' -<.. DATE RECEIVED: 'it/ VI DATE ISSUED: © A Address: /6,� d S P��� die e (D,b ry . .,..;, -.. ,.. , + hi r\i., r Ai ,� r Telephone Numbers: Home: Briefly describe use of adjoining property: North: V/4 t i.I,J7' eb.ti%. aim i 1. k.i 1 L- East: IJu: i L J c,, p . KF „,w sn= �T� , i..... ... 6r ' '�, ci L. �3� APPLICATION NO: DATE {S) OF EVENT: ! . i 41 ... ` / D / (L B�OO ”. ;tog f�, FEE: $175.00 / " 1 -- DATE PAID: If Non- Profit/Civic Organization iq 4 ' Date: Building Inspector Approval: t,t1 LI A I L4-1— r TEMPORARY USE PERMIT APPLICATION ;� -S01 3(t�i�iStiC`C OTHER TEMPORARY STRUCTURES (SEC 666 APPLICANT 11 Name of Property Owner(s): 7. k 1-kepi J.-es 0_ f diAtediektite f3I 14.2n 74,,af. �/ © A Address: /6,� d S P��� die e (D,b ry . .,..;, -.. ,.. , + hi r\i., r Ai ,� r Telephone Numbers: Home: Briefly describe use of adjoining property: North: V/4 t i.I,J7' eb.ti%. aim i 1. k.i 1 L- East: IJu: i L J c,, Work: Mobile /Cell: Pager: Public Works Department Approval. Name of Applicant: / ' Date: Building Inspector Approval: Date: j City Administrator Approval: Address: S ,ate; fj � � .�C�( i 1 C - Telephone Numbers: Home: Work: Mobile /Cell: 7L47-- 3r'_' % : DL tz t aOther w a o co C. Future Land Use Map Designation: Current Zoning Designation: /../ L/ Legal Description of Property: L c'i ; I i . a , l i r, y.i 0104 1< 42- ti Address of Property: / ti, 0 o 6 t- a ei C% i t Fl Ls( Please Explain Type of Use: &I tl, r 1)r'cr1, i._ t is CY lis a IA,- `.�f, Briefly describe use of adjoining property: North: V/4 t i.I,J7' eb.ti%. aim i 1. k.i 1 L- East: IJu: i L J c,, South: hi ,...‘4 elti ,,,i,,i, i s West: jJc (, f..i(,tj ► el,' temporary structures subject to the following regulations: 1. Christmas tree, fireworks and similar seasonal sales operated, by a non - profit organization. 2. Carnival, circus, fair or other special event operated by a non- profit organization on or abutting their principal use. 3. Commercial carnival, circus or fair in commercial or industrial districts. 4. Similar temporary structures where the period of use will not exceed 30 days a year. The applicant shall: --_:-Submit proof of liability insurance, paid in full covering the period for which the permit is issued, in the minimum amount of $1,000,000.00 per occurrence. 2. Remove all debris within 48 hours of expiration of permit Have notarized written permission of property owner, if applicant is not the property owner. (Submit Site Plan * inspection Certificate(s) * .8.-- &+bruit -State - Aimuat-- Permit I hereby certify that the information on this application is correct. The information Included in this application is for use by the City of Okeechobee in process] • •• y request. False or misleading information may be punishable by a fine of up to $500.00 and imprison • • • t. rt -ys and may result in the summary denial of this application. /;/r,1 241 Date Sig !!r o - ..,►�, City Staff (Please review the application, attach comments or special conditions): Occupational and /or State License Verification: / 1 ... t3ti lila, Date: / ,., 41 Y .c:›Y/4,9 Date: Fire Department Approval: Police Department Approval: -u Date: Public Works Department Approval. ' Date: Building Inspector Approval: Date: j City Administrator Approval: L Datey'6 !r «V(c, Revised 211/08 bic Goo* earth /(0 sireAlr feet meters PAAfivir 10 3 Art. MOT hirt41 Cr 4111114 A /0 X 10 D & K Enterprises of Okeechobee, Inc. Brahman Theaters 111 P.O. Box 1395 Okeechobee, Florida 34973 To Whom It May Concern: I, Karla H. Roby and Debra S. Sales, owners of The Brahman Theatres IIf, located at 1500 S. Parrott Avenue in Okeechobee. Give permission for Chobee Nation Fundraiser, the use of our parking lot on Friday, April 15th, 2016 for a BBQ benefit. Best Regards, Karla H. Roby Debra S. Sales • CHAKA -1 OP ID: MB ACCOR� �- CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 04/05/2016 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 ISU Lawrence Insurance Agency PO Box 549 Okeechobee, FL 34973 Heath Lawrence CONTACT PHONE FAX (A /C, No, Ext): (A /C, No): POLICY EXP /Y (MM /DDYYY) E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A : Scottsdale Insurance Co 41297 INSURED Chakas Stars Foundation Inc Chaka Stars Cheer PO Box 791 Okeechobee, FL 34973 -0791 INSURER B: 06/15/2015 INSURER C : EACH OCCURRENCE INSURER D : DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER E : MED EXP (Any one person) INSURER F : COVERAGES CERTIFICATE NUMBER: 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. NOTVVITHSTANDING 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 INSURANCE ADDL INSR SUBR W VD POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP /Y (MM /DDYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CPS2256594 06/15/2015 06/15/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 CLAIMS -MADE X OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP /OP AGG $ 3,000,000 GE X 'L AGGREGATE POLICY LIMIT APPLIES JECT PRO PER: LOC $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY ERTY DAMAGE ACCIDENT) $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CANCELLATION CTYOKEE City of Okeechobee 55 S.E. 3rd Avenue Okeechobee, FL 34974 I 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 (2010/05) ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Detail by Entity Name FLORIDA DEPARTMENT OF STATE DIVISION OF CORPORkTIONS Page 1 of 3 Detail by Entity Name Florida Not For Profit Corporation CHAKA'S STARS FOUNDATION, INC. Filing Information Document Number N07000001082 FEI /EIN Number 20- 8348641 Date Filed 01/31/2007 State FL Status ACTIVE Last Event AMENDMENT Event Date Filed 08/21/2007 Event Effective Date NONE Principal Address 1491 SW 86TH AVENUE OKEECHOBEE, FL 34974 Mailing Address 1491 SW 86TH AVENUE OKEECHOBEE, FL 34974 Registered Agent Name & Address SMITH, CHAKA 1491 SW 86TH AVENUE OKEECHOBEE, FL 34974 Officer /Director Detail Name & Address Title P SMITH, CHAKA 1491 SW 86TH AVENUE OKEECHOBEE, FL 34974 Title VP KOGER, DEREK 3816 NW 34TH AVE OKEECHOBEE, FL 34972 Title Director http: // search. sunbiz. org / Inquiry / CorporationSearch /SearchResultDetail ?inquirytype= Entity... 4/5/2016 Detail by Entity Name Page 2 of 3 CLEVELAND, TINA 1913 FIREFLY DR GREEN COVE SPRINGS, FL 32043 Title T SMITH, SURAIYA 14S1SVVO8THAVENUE OKEECHOBEE, FL 34974 Title S MORRIS, TERRA 1391NVV14THAVE OKEECHOBEE, FL 34972 Title VP CLEVELAND, KEVIN 1913 FIREFLY DR GREEN COVE SPRINGS, FL 32043 Title Director MILLER, LASHAWN 2O21NVV 7TH AVENUE OKEECHOBEE, FL 34972 Annual Reports Report Year 2013 2014 2015 Document Images Filed Date 05/14/2013 04/25/2014 02/27/2015 02/27/2015 -- ANNUAL REPORT 04/25/2014 -- ANNUAL REPORT O5/14/2U13— ANNUAL REPORT 05/25/2012 -- ANNUAL REPORT 02/22/2011 -- ANNUAL REPORT 02/09/2010 -- ANNUAL REPORT 04/22/2009 -- ANNUAL REPORT 03/25/2008 -- ANNUAL REPORT 08/21/2007 -- Amendment 01/31/2007 -- Domestic Non-Profit View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 4/5/2016