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HIS Church BBQ FundraiserCity of Okeechobee 55 S.E. 3rd Avenue Okeechobee, Florida 34974 (863) 763-9821 Temporary Use Permit Permit Number: 17-006 Date(s) of Event: Dec 01, 2017 10AM — 4PM Permit Expiration: December 01, 2017 11:59PM Purpose of Request: His Church BBQ Fundraiser — Pick up Only Property Owner: Karla Roby & Debra Sales Address: 1906 SW 5th Avenue City: Okeechobee State: Florida Zip Code: 34974 Applicant: His Church -It's Jesus Church Applicant's Address: 1167 Linda Rd., Okeechobee Phone Number: 863-357-6500 Address of Project: 1600 S Parrott Ave Current Zoning: Heavy Commercial (CHV) FLU Designation: Commercial (C) Subdivision: 1St Addition S Okeeechobee Lots 1-12 & alley Block 29 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 additional permits required from other governmental entities. Applicant's Signature Date: rjpC1 ,T DDate: November 15, 2017 Administrative Secretary REF: .ORD.716, Temporary Structures CITY OF OKEECHOBEE General Services Department, Room 101 55 Southeast 3' Avenue Okeechobee, FL 34974 Phone: 863-763-3372 ext. 218 Fax: 863-763-1686 $.''"' ' o ,. _,,,," Name of Property Owners):.Rckti \Ar H i >f)LEF, bE s DATE RECEIVED: DATE ISSUED: Telephone Numbers: Home: Work: Mobile/Cell: Pager: Name of Applicant:`r" wElAorzio ryr. '—•m: ) _ +GSn '. r._..' ' 6r APPLICATION N0: 'DATE(S) OF EVENT: I "1 -00(9 1 Wt�'�� "fir 1J�C 01) IOWA - yt'.M . A/ Date:/�(v �nlT o� FEE: $175.00 DATE PAID: r,j L\ ta(If Non-Profit/Civic Organization TEMPORARY USE PERMIT APPLICATION OTHER TEMPORARY STRUCTURES (SEC 666 APPLICANT I) Name of Property Owners):.Rckti \Ar H i >f)LEF, bE s Address: 19(3L SU) - AVE Telephone Numbers: Home: Work: Mobile/Cell: Pager: Name of Applicant:`r" wElAorzio Address: [kZo% LVvOq '\k, O'KEECV))-_ FL 3 X114 , Telephone Numbers: Home: Work: Pi.,1 357 1pci1;:Mobile/Cell: Siz3• 1.01O 3i` Pager: - CG N I 3 a • (' U PROPERTY II Future Land Use Map Designation: Current Zoning Designation: 0_1.4 t f Legal Description of Property: j-tRST Xt6a-tG:► 1?,yili 0k.EL'copplE tom -12 Address of Property: I J,,co cs'FiRRd1- kisOkk( E�) FL q7 i Please Explain Type of Use: pc tr't)),ANz.B6r'12, `� tctk UP QIiLI.? Briefly describe use of a911 oining property: `� North: L\Gf+TSt� Lis '5_ --11i rj East: kilnt RR15 C y South: 1*3 ply West: blf30Slci er,kirm Other 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: 1. 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 3. Have notarized written permission of property owner, if applicant is not the property owner. 4. Submit Site Plan * Submit State inspection Certificate(s) * 66. Submit State Annual Permit I hereby certify that the information on this application is correct. The Information included In thus application is for use by the City of Okeechobee in processing my request. False or misleading information may be punishable by a fine of up to $500.00 and imprisonment of up to thirty days and may result in the summary denial of this application. Date Signature of Applicant conditions): Occupational and/or State License Verification: (, %�/ry��O nn >(,t%L� Date:///g /� Fire Department Approval: I' . A/ Date:/�(v �nlT o� Police Departmen Date: Public Works Department App • - /'-"-----: Dat .j/ -1C-0 Building Inspector Approv- C - Date: " *0, `7 City Administrator Approval% Date: 2- V?) -- Revised 2J1108 b(c Pj(UAvhx..h ()(),.(L;bn lo+' i i 1 I 1 1,11 t Go ,0x(0 BRAHMAN THEATER III P.O. Box 1395 Okeechobee, Florida 34973 1 s We give permission to H act\ , to hold a fundraiser on Our property located at 1500 S. Parrot Avenue, on 'Dee- 1 , 2017. Said party is responsible for all trash removal for stated event. X IL' ,c%, Debra S. Sales Owner x -ko.uf 014 Rc)cr Karla H. Robv Owner INTERNAL REVENUE SERVICE P. O. BOX 2508 CINCINNATI, OH 45201 Date: V t teO 4 HIS CHURCH - ITS JESUS CHURCH INC 1167 LINDA RD OKEECHOBEE, FL 34974 Dear Applicant: DEPARTMENT OF THE TREASURY Employer Identification Number: 47-0978467 DLN: 17053253309014 Contact Person: DAVID A DOEKER ID# 31168 Contact Telephone Number: (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 170(b) (1) (A) (i) Form 990 Required: No Effective Date of Exemption: June 3, 2014 Contribution Deductibility: Yes Addendum Applies: No We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c)(3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c)(3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter "4221 -PC" in the search bar to view Publication 4221 -PC, Compliance Guide for 501(c)(3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Letter 947 HISCH-2 OP ID: IH '4c.-- CERTIFICATE OF LIABILITY INSURANCE �'� DATE `M /201YYY' 11 /08/2017 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 Pritchards & Associates, Inc. 1802 S Parrott Ave Okeechobee, FL 34974-6179 Lowell H Pritchard NAMEACT Lowell H Pritchard PHO No, Ext): 863-763-7711 FAX No): 863-763-5629 -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: First Nat'l Ins Co of America 24724 INSURED His Church -Its Jesus Church Inc.aka Buckhead Ridge 1167 Linda Road Okeechobee, FL 34974 INSURERB: INSURERC: INSURER D: $ 1,000,000 INSURER E : INSURER F : -i CLAIMS -MADE I -i OCCUR 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. 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 LTR TYPE OF INSURANCE INSD WL R VD POLICY NUMBER POLICY EFF (MM1DDlYYYY) POLICY EXP (MMlDD7YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 -i CLAIMS -MADE I -i OCCUR 01 C181015430 06/26/2017 06/26/2018 DAMAGE PREMISES ( TO RENTEDEaoccurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 $ 1,000,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE POLICY PRO- JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ _ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB _ CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER STATUTE H- ER AND EMPLOYERS' LIABILITY Y ANY PROPRIETOR/PARTNER/EXECUTIVEN r N E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED (Mandatory In NH) A E L DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ A A Property Section Equipment Floate 01C181015430 01C181015430 06/26/2017 06/26/2017 06/26/2018 06/26/2018 DESCRIPTION OF OPERATIONS 1 LOCATIONS( VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) BRAHM-1 Brahman Theater Debbie Sales & Karla Roby PO Box 1395 Okeechobee, FL 34973 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 C7�GY /��`�: n ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD