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Temp. Use Permit - HIS Church BBQ FundraiserCity of Okeechobee 55 S.E. 3rd Avenue Okeechobee, Florida 34974 (863) 763-9821 Temporary Use Permit Permit Number: 19-004 Date(s) of Event: May 31, 2019 10AM-2PM Permit Expiration: May 31, 2019 11:59PM Purpose of Request: His Church BBQ Fundraiser Property Owner: Pritchard & Associates Address: 1810 S Parrott Avenue City: Okeechobee State: Florida Zip Code: 34974 Applicant: His 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: 1S Addition South Okeeechobee Lots 1-6 & Block 35 Restrictions/Remarks: All debris must be removed upon final completion date. Per Fire Chief, fire extinguisher must be on site unless a nearby business within 75' of the event will have one available to use. 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 Administrative Secretary REF: .ORD.716, Temporary Structures Date: Date: April 1, 2019 Revised 1/5/18 jd Yom. TEMPORARY USE PERMIT APPLICATION OF• fF4 .p? _ �� OTHER TEMPORARY STRUCTURES (666) �� -.°',1 { E.. �,�Z City of Okeechobee - General Services Department . -,---z,------ �� -: O w --��- a 55 SE 3rd Ave, Room 101, City Hall, Okeechobee, FL 34974 .,,,,,,, • Phone: (863) 763-3372 ext. 9821 DATE RECEIVED: "- - ?A .1 DATE ISSUED: 5 - 1 - I lea, APPLICATION NO.: 14'_011 EVENT DATE(S) & TIME: \\t)$( R.N.f 31 c ° (IAN FEE: $175.00 ?t'41/i1., [ lon-Profit/Civic Organization DATE PAID: IN (A - Name of Property Owner(s): rs . cv N N 1), IN c -lo cj m \1_ `:G i' Address: 1 vG r=,,jo d T',I(p5Ic N Glc, Nk.kc i `k t Telephone Numbers: Home: ( LA) 1-nsA.-x'71 S \ Work: Cell: Name of Applicant: �d1` YV-70A err ;C' Fila 5 c./t(ttACs r / . 6' 11I a Address: 11 L> i_ p �1) e sWkiai �t_ 'okeni'\ t Telephone Numbers: Home: '; its'?) ` — (eSGIO Work: Cell: Future Land Use Map Desigation: C Current Zoning Designation: e.(t v% Legal Description of Property: r i.,2,j'; Ai.)4: i 4 'v11 C6, u,:l'U cAt i.: `.Ja 't;u.1. i S f -- tE &--K %e Address of Property: l Z3'L() Sourrj WItItza km_ Please Explain Type of Use: na RA.J.m?4,1ksER., Briefly describe use of adjoining property North: �� `�C`W41 \.)1/4.1.5 _ East: \ South: •NAPr 1\1\u West:S./TT( \o 1 Other temporary structures subject to the following regulations: 1. Christmas tree, fireworks and similar seasonal sales operated by a non-profit organizaiton. 2. Camival, circus, fair or other special event operated by a non-profit organization on or abutting their principal use. (*additional information required) 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. Have notarized written permission of property owner, if applicant is not the property owner. 3. Remove all debris within 48 hours of expiration of permit. 4. Submit Site Plan, State Inspection Certificates and submit State Annual Permit * City Staff (Please review the application, attach comments or special conditions). Occupational and.or State License Verification:lOil `%/� ��, Date: / J g 7, 019 Fire Department Approval: , r 1- Irs- --X-- IA'etaars A,rlbil�t Date: D7. /l7f4/J0/4 Police Department Approval: Date: . -"� V.--/-: Public Works Department Approval: %"'__— Date: 5-- D --I 44 Building Inspector Approval:�' Date: S. ( - rA City Administrator Administrator Approval: \� -- � J Date: ���y I hereby certify that the information on this application False or misleading information may be punishable is co ect. he information included by,a fine of up to $500.00 and imprisonment in this application is for use by the City of Okeechobee in processing my request. of up to thirty days and may result in the summary denial of this application. Signature of Applicant Date 7 INTERNAL REVENUE SERVICE P. O. BOX 2508 CINCINNATI, OH 45201 Date: btu ;, /Z014 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 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 ID# 31168 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 -2 - HIS CHURCH - ITS JESUS CHURCH INC We have sent a copy of this letter to your representative as indicated in your power of attorney. Sincerely, Director, Exempt Organizations Letter 947 Ai® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 4/30/2019 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 Pritchards & Associates, Inc 1802 S Parrott Ave Okeechobee FL 34974 CON !ACT NAME: Taylor Padrick (A/C, No, Ext): (863) 763-7711 ONE FAX No): AADDDREDRE SS: toCSPritchardsinc.com Yfor INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : First Nat'l Ins Co of America COMMERCIAL GENERAL LIABILITY INSURED His Church PO BOX 1000 OKEECHOBEE FL 34973 INSURER B : BKS58625053 INSURER C : 06/26/2019 INSURER D : $ 1,000,000 INSURER E : $ 1,000,000 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. 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 NSURANCE 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 AUUL INSD SUM( WVD POLICY NUMBER POLICY E -F (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY BKS58625053 06/26/2018 06/26/2019 EACH OCCURRENCE $ 1,000,000 PREMISES (Ea occurrence) $ 1,000,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 15,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES 'E0 PER: LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY - SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINULE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PHUPEH I Y UAMAUL (Per accident) $ $ UMBRELLA LIAB_ EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N / A STATUTE ER H E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Pritchard And Associates Inc 1802 S Parrott Ave Okeechobee FL 34974 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 I Owe.1-L U. ?rUati .t -d. ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD pA..4,',141 To F. b. vlaa� APPLICATI N FOR SPECIAL EVENT Application #: 1 4 '0 0 y Date Submitted: 4-30 I q Permit #: NAME OF EVENT: 1"415 et4 CV\ 1B0�Diu'r15t^R ADDRESS OF EVENT: 1810 5tjTh FUS . • DESCRIPTION OF EVENT: W j NAME OF SPONSOR ORGANIZATION: Contact Number before and during event OF RESPONSIBLE PERSON: 1 tVcrt ( (OGt-i ce DATE(S) AND TIME(S) OF EVENT: Date: 5/5x r/ l e\, Starting Time: C\ANt Closing Time: ZPM Date: Starting Time: Closing Time: Date: Starting Time: Closing Time: ARE ANY ROA WAYS 7['O !:;E 1LOCIKED/CLOSED? On LOCATION IIF Will Emergency Apparatus (Fre and Ambulance) have access to area?` -?i:`3 NO, THEN EXPLAIN (provide alternatives): WILL ELECTRICITY i..E USED? YES ❑ ONO Fe Locations: Provided By: WILL HEATING/OPEN FLAMES FOR FOOD i:;E PROVIDED? YES g❑NO ❑ Type of Heating Equipment Used: LAttc,F 53kf WILL A TENT BE ERECTED? Tent Manufacturer: (52MO C Tent have sides and how many? 56 YES W NO D Size x1O fire rating posted: ***ATTACH SITE MAP OF EVENT LAYOUT*** The following items to be completed by Fire Department only FIRE DEPARTMENT LIFE SAFETY & FIRE SERVICES REQUIREMENTS: (See above) 0_ -. _ _ . - . --quired. - 0 Tent Size r.'q fire lite -safety inseotion_ fl square feet or lessthee-require • .. - fl en ac Fire extin. .shers must have current to - - i . ..' ' • w . e ig c er nspec 1'• - • EQUIPMENT) and be operational and readily access ■• -.11 . - .. FIRE DEPARTMENT OFFICIAL (P INT): SIGNATURE: Please call the FD at 863-467-1586 for any questions. To whom it may concern, On behalf of Pritchard's and Associates Inc. Insurance, authorize His Church — It's Jesus' Church Inc. to conduct a BBQ Fundraiser at 1810 South Parrot Avenue; on Friday, May 31, 2019 from 10am — 2pm. I ER Jay May SOL_ '1 $10 Donation per Dinner Sliced Por<, Bakec Beans, Cole Slaw, at a Rol \\. Love ! Crow Serve 1810 So ot Avenue Ticket uadZ — uae6 6ZOZ `Z£ dew Aapu j Jasieapund beg tpanLD s!H ow wined ulnoS 3081 t any u1noS 0181 N tip F-' > rD 0 4111111111111111111 +01101111111111 .frvmc,,;:u:.Nx ar mc.ae rs,'aeri35,,q..s ._'sx r sxa waopn'o^z magow, ' Amadeus Hall