chicityclerk.s3.amazonaws.comchicityclerk.s3.amazonaws.com/s3fs-public/document_uploads/coun… ·...

City Hall121 North LaSalle Street

Room 107Chicago, IL 60602

www.chicityclerk.com

City of ChicagoOffice of the City Clerk

Legislation Referred to Committees at the Chicago City Council Meeting5/20/2015

Section 2b - City Clerk Introductions Containing Economic Disclosure Statements

Zoning Reclassification(s)

ZoningZoning Reclassification Map No. 1-F at 130N Franklin St - App No. 18381

O2015-41741 RedactedRecord

City Clerk(transmitted by)

ZoningZoning Reclassification Map No. 7-F at 506-514 W Diversey Ave - App No. 18382



ZoningZoning Reclassification Map No. 1-F at 640N Wells St - App No. 18383



ZoningZoning Reclassification Map No. 4-H at 1911W Cullerton St - App No. 18384



ZoningZoning Reclassification Map No. 9-M at 5800W Addison St - App No. 18385



ZoningZoning Reclassification Map No. 3-I at 2440W Division St - App No. 18386



ZoningZoning Reclassification Map No. 7-L at 2820N Cicero Ave and 4800-4830 W DiverseyAve - App No. 18387



ZoningZoning Reclassification Map No. 12-L at5148-5158 S Long Ave - App No. 18388



ZoningZoning Reclassification Map No. 6-H at 1951W 22nd Pl - App No. 18389T1



ZoningZoning Reclassification Map No. 9-H at 3530N Lincoln Ave - App No. 18390



TitleFile # Committee ReferralSponsor(s)

Created by the Office of the City Clerk, City of Chicago Report Generated on 5/21/2015 at 9:10 AM of 1

City of Chicago

Office of the City Clerk

Document Tracking Sheet

02015-4174

Meeting Date:

Sponsor(s):

Type:

Title:

Commlttee(s) Assignment:

5/20/2015

City Clerk (transnnitted by)

Ordinance

Zoning Reclassification Map No. 1-F at 130 N Franklin St -App No. 18381 Committee on Zoning, Landmarks and Building Standards

^\%1> 8 I

ORDINANCE

BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO

SECTION 1. That the Chicago Zoning Ordinance be amended by changing all of the DC-16 Downtown Core District symbols and indications as shown on Map 1-F in the area bounded by:

West Randolph Street; North Franklin Street; West Washington Street; a line 161.70 west of and parallel to North Franklin Street; the public alley next south of and parallel to West Randolph Street; the public alley next west of and parallel to North Franklin Street;

to those of a Business Planned Development.

SECTION 2. This Ordinance shall be in force and effect fi-om and after its passage and publication.

Applicant: 130 North Franklin Development, LLC Address: 130 North Franklin, Chicago, IL 60601 Introduced: May 20, 2015 Plan Commission: TED

EAST\97626497,1

BUSINESS PLANNED DEVELOPMENT NO. PLANNED DEVELOPMENT STATEMENTS

1. The area delineated herein as Planned Development Ntimber TBD, ("Planned Development") consists of approximately 65,382 square feet of property which is depicted on the attached Planned Development Boundary and Property Line Map ("Property"). Tishman Speyer Development, L.L.C. is the "Applicant" for this planned development with the authorization of the owner of the Property.

2. The requirements, obligations and conditions contained within this Plaimed Development shall be binding upon the Applicant, its successors and assigns and, i f different than the Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to the requirements of Section 17-8-0400 of the Chicago Zoning Ordinance (the "Zoning Ordinance"), the Property, at the time of application for amendments, modifications or changes (administrative, legislative or otherwise) to this Plaimed Development, shall be imder single ownership or designated control. Single designated control is defined in Section 17-8-0400 of the Zoning Ordinance.

3. All applicable official reviews, approvals or permits are required to be obtained by the Applicant or its successors, assignees or grantees. Any dedication or vacation of streets or alleys or grants of easements or any adjustment of the right-of-way shall require a separate submittal to the Chicago Department of Transportation ("CDOT") on behalf of the Applicant or its successors, assigns or grantees.

Any requests for grants of privilege, or any items encroaching on the public way, shall be in compliance with the Plans.

Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Department of Planning and Development ("DPD") and CDOT. Closure of all or any public street or alley during demolition or construction shall be subject to the review and approval of CDOT.

All work proposed in the public way must be designed and constructed in accordance with CDOT Standards for Work in the Public Way and in compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by CDOT.

4. This Plan of Development consists of these 15 Statements; a Bulk Regulations and Data Table and the following exhibits and plans attached hereto prepared by Krueck + Sexton and

Applicant: 130 North Franklin Development, LLC Address: 130 North Franklin, Chicago, Illinois 60606 Introduced: May 20, 2015 Plan Commission: TBD

1 EAST\97625604.2

dated (the "Plans"): an Existing Zoning Map; an Existing Land-Use Map; a Planned Development Property and Boundary Line Map; a Site Plan; a Landscape Plan; a Green Roof Plan; and Building Elevations (North, South, East and West). Full-sized copies of the Site Plan, Landscape Plan and Building Elevations are on file with the DPD. In any instance where a provision of this Planned Development conflicts with the Chicago Building Code, the Building Code shall control. This Planned Development conforms to the intent and purpose of the Zoning Ordinance, and all requirements thereof, and satisfies the established criteria for approval as a Planned Development. In case of a conflict between the terms of this Planned Development Ordinance and the Zoning Ordinance, this Planned Development Ordinance shall control.

5. The following uses are permitted in the area delineated herein as a Business Planned Development: all uses allowed in the DC-16 Downtovm Core District including, but not limited to. Colleges & Universities; Postal Service; Animal Services; Business Equipment Sales and Service; Business Support Services; Eating and Drinking Establishments (all); Financial Service; Food and Beverage Retail Sales; Office; Personal Service; General Retail Sales; Non-Accessory Parking; and related, incidental and accessory uses and parking.

6. On-Premise signs and temporary signs, such as construction and marketing signs, shall be permitted within the Planned Development, subject to the review and approval of DPD. Off-Premise signs are prohibited within the boundary of the Planned Development.

7. For purposes of height measurement, the definitions in the Zoning Ordinance shall apply. The height of any building shall also be subject to height limitations, i f any, established by the Federal Aviation Administration.

8. The maximum permitted Floor Area Ration ("FAR") for the Property shall be in accordance with the attached Bulk Regulations and Data Table. For the purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted FAR identified in the Bulk Regulations and Data Table has been determined using a Net Site Area of 65,382 square feet and a base FAR of 16.0, and additional FAR for proposed FAR bonuses as follows:

Description FAR Base FAR: 16.00 Plaza Bonus: 5.0663 Total FAR: 21.0663

9. Upon review and determination, "Part II Review", pursuant to Section 17-13-0610 of the Zoning Ordinance, a Part I I Review Fee shall be assessed by DPD. The fee, as determined


EASB97625604.2

by staff at the time, is final and binding on the Applicant and must be paid to the Department of Revenue prior to the issuance of any Part I I approval.

10. The Site and Landscape Plans shall be in substantial conformance with the Landscape Ordinance and any other corresponding regulations and guidelines. Final landscape plan review and approval will be by DPD. Any interim reviews associated with site plan review or Part I I reviews, are conditional until final Part II approval.

11. The Applicant shall comply with Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation, Fleet and Facility Management and Buildings, under Section 13-32-125 of the Municipal Code, or any other provision of that Code.

12. The terms and conditions of development tmder this Planned Development ordinance may be modified administratively, pursuant to section 17-13-0611-A of the Zoning Ordinance by the Zoning Administrator upon the application for such a modification by the Applicant, its successors and assigns and, i f different than the Applicant, the legal title holders and any ground lessors.

13. The Applicant acknowledges that it is in the public interest to design, construct and maintain the project in a manner which promotes, enables and maximizes universal access throughout the Property. Plans for all buildings and improvements on the Property shall be reviewed and approved by the Mayor's Office for People with Disabilities to ensure compliance with all applicable laws and regulations related to access for persons with disabilities and to promote the highest standard of accessibility.

14. The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resotxrces. The Applicant shall seek LEED certification and provide a 50% net green roof equivalent to an actual total of 25,004 square feet.

15. This Planned Development shall be governed by Section 17-13-0612 of the Zoning Ordinance. Should this Planned Development ordinance lapse, the Commissioner of DPD shall initiate a Zoning Map Amendment to rezone the property to the DC-16 Downtown Core District.


EAST\97625604.2

BUSINESS PLANNED DEVELOPMENT NO. BULK REGULATIONS AND DATA TABLE

Gross Site Area (sf):

Area of Public Rights-of-Way (sf):

Net Site Area (sf):

Maximum Floor Area Ratio:

Minimum Off-Street Parking Spaces:

Minimum Off-Street Loading Spaces:

Maximum Building Height:

Minimum Setbacks:

99,856.69 SF (2.29 acres)

34,474.69 SF (0.79 acres)

65,382 SF (1.50 acres)

21.0663

140

4 (10'x 25')

In substantial conformance with Plans

In substantial conformance with Plans

Applicant: 130 North Franklin Development, LLC Address: 130 North Franklin, Chicago, IL 60601 Introduced: May 20,2015 Plan Commission: TBD

EASTA97626036.2

DLA PSPER DLA Piper LLP (US) 203 North LaSalle Street, Suite 1900 Chicago, Illinois 60601-1293 www.dlapiper.com

Katherine C. Jahnl<e Dale [email protected] T 312.368.2153 F 312.251.2856

May 13, 2015

The Honorable Daniel Solis, Chairman City of Chicago Committee on Zoning Room 304, City Hall 121 North LaSalle Street Chicago, Illinois 60602

Martin Cabrera, Jr., Chairman City of Chicago Plan Commission Room 1000, City Hall 121 North LaSalle Street Chicago, Illinois 60602

Re: Application for Business Planned Development 130 North Franklin Development, LLC

Dear Chairman Solis and Chairman Cabrera:

The undersigned, Katherine C. Jahnke Dale, an attorney with the law firm of DLA Piper LLP (US), which firm represents 130 North Franklin Development, LLC, the applicant for an amendment to the Chicago Zoning Ordinance and proposed planned development, certifies that she has complied with the requirements for Section 17-13-0107 of the Chicago Zoning Ordinance by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet of each direction of the lot line of the subject property, exclusive of public roads, streets, alleys and other public ways. Said written notice was sent by First Class U.S. Mail, no more than 30 days before filing the application.

The undersigned certifies that the notice contained the address of the property sought to be rezoned; a statement of the intended use of the property; the name and address of the applicant; the name and address of the owner; a statement that the applicant intends to file the application for change in zoning on approximately May 13, 2015, and a source for additional information on the application.

The undersigned certifies that she has made a bona fide effort to determine the addresses of the parties to be notified under Section 17-13-0107 of the Chicago Zoning Ordinance, and that the accompanying list of names and addresses of surrounding property owners within 250 feet of the subject site is a complete list containing the names and addresses of the people required to be served.

Very truly yours,

DLA Piper LLP (US)

Katherine C. Jahnke Dale

Subscribed and sworn to before me

0111012016.

EAST\97626328 .1

DLA PIPER DLA Piper LLP (US) 203 North LaSalle Street, Suite 1900 Chicago, Illinois 60601-1293 www.dlapiper.com

Richard F. Klawiter [email protected] T 312.368.7243 F 312 630.7337

May 13, 2015

FIRST CLASS MAIL

Dear Sir or Madam:

As required by Section 17-13-0107 of the Municipal Code of the City of Chicago, please be informed that on or about May 13, 2015, the undersigned, on behalf of 130 North Franklin Development, LLC (the "Applicant"), intends to file an application to rezone the property located at 130 North Franklin, Chicago, IL 60601 from the DC-16 Downtown Core District to a Business Planned Development. A map of the development site is printed on the reverse side of this letter.

The development site is currently utilized as a surface parking lot and vacant. The Applicant seeks approval of plans for a new 53-story office building with ground floor commercial and restaurant space, 140 on-site parking spaces and accessory uses. A large plaza containing approximately 20,700 square feet of landscaped open space will exist adjacent to the proposed building at the first floor level.

The proposed change of zoning does not apply to your property. You are receiving this notice as required by the Chicago Municipal Code because the Cook County Assessor's records indicate that you own property within 250 feet of the development site.

I am an authorized representative of the Applicant and my address is 203 North LaSalle Street, Suite 1900, Chicago, IL 60601. Henry Crown & Company d/b/a CC Industries is the owner of the property and has an address of 222 North LaSalle Street, Chicago, Illinois 60601. The Applicant's address is c/o Tishman Speyer, 45 Rockefeller Plaza, New York, NY 10111.

Please contact me at 312-368-7243 with questions or to obtain additional information.

Very truly yours,

DLA Piper LLP (US)

Richard F. Klawiter

EAST\97626237.1

OWNER'S AUTHORIZATION

The undersigned, HENRY CROWN & COMPANY D/B/A CC INDUSTRIES ("HC&Co,"), being the legal titleholder of certain real property commonly known as 130 North Franklin Street, Chicago, Illinois (the "Subject Property"), hereby authorizes TISHMAN SPEYER DEVELOPMENT, L.L.C, a Delaware limited liability company ("Tishman"), and DLA PIPER LLP (US) ("DLA") to file an application with the City of Chicago seeking approval of a Planned Development for purposes of constructing a commercial office project on the Subject Property; provided, however, that such authorization may be withdrawn by the undersigned at any time prior to any approvals. Further, Tishman and DLA agree to keep HC&Co. fully advised of the process and to provide copies of all submissions prior to filing and advance notice of all hearings and proceedings.

IN WITNESS WHEREOF, the undersigned has executed this Owner's Authorization as ofthisd^fAday of f t P K / L 2015.

HENRY CROWN & COMPANY D/B/A CC INDUSTRIES, a Delaw^ corporation

Name>^James S. Crown T j . t l ^ President

AGREED TO:

Tishman..^pey^ Development, L.L.C.

Byv

4853-0368-2595, V. 2

OWNER'S AUTHORIZATION

TISHMAN SPEYER DEVELOPMENT, L.L.C. being the authorized applicant for a Planned Development relating to that certain property located at 130 North Franklin Street, Chicago, Illinois (the "Property"), hereby authorizes 130 NORTH FRANKLIN DEVELOPMENT, L.L.C. and its attorneys, DLA Piper LLP (US), to file an application for a Planned Development and to seek such other permits and land use approvals as may be necessary or desirable to allow construction of a commercial/office project on the Property.

IN WITNESS WHEREOF, the undersigned has executed this Authorization as of this day of 2015.

TISHMAN^PEYER DEVELOPMENT, L.L.C.

By Name

MAN^PEYER DEVELOPMEl

y- j g. • (ubPmsidBiil&SfcRjrotary

EAST\100680331,1

Officers:

Exhibit "A"

Executive Officers and Directors of Henry Crown and Company

Lester Crown Charles H. Goodman James S. Crown William H. Crown

A. Steven Crown William C. Kunkier, ill Michael S. Canmann Ryan Stewart James A. Star Richard H. Robb Kirk Rose David M. Rubin Rahul Danak Mark Hoffman Joy Schaum Maureen Flynn Michael Podgorski James Biegel Brian B. Gilbert Marvin Bailey, Sr. Daniel Dahlberg Dan Crown

Chairman Vice Chairman President Vice President, President/Chief Executive Officer of CC Industries Inc. Division, Executive Vice President and Chief Financial Officer Vice President Vice President - Operations Executive Vice President and Chief Financial Officer Vice President Vice President Vice President Senior Vice President - Tax and Accounting Vice President - General Counsel and Secretary Vice President - Accounting & Corporate Controller of CC Industries, Inc. Division Vice President - Information Systems and Technology Vice President - Tax Planning Vice President - Accounting & Corporate Controller of CC Industries, Inc. Division Treasurer Vice President-Tax and Compliance Assistant Secretary Vice President - Land Development Vice President-Community Relations Vice President

Directors:

Lester Crown Charles H. Goodman James S. Crown William H. Crown A. Steven Crown

4835-1442^9471, V. 1

EXHIBIT B

Rebecca Eileen Crown Trust

Arie Steven CrouTi Trust

James Schine CrowTi Trust

Daniel Morris Crown Trust

Nancy Jean Crown Trust

Patricia Ann Crown Trust

14.05% owner

17.84% owner

8.69% owner

5.16% OAvner

5.75% owner

5.16% owner

Map of Development Site

I

• ! ll-i la i

J L L

r

PINs:

17-09-441-002, -003, -005, -006

17-09-442-007, -008

EAST\97626237.1

EXISTING LAND-USE MAP

I CHICAGO RIVER

\

• PD Boundary Line ' Property Line • Dedicated Alley Below 29' CCD

PARKING

OFFICE

OFFICE

•Fici: OF=IC

RETAIL

PARKING | _ -

E 0=FICE

DedicBled Alley.

1! OFFICE Dedicated * _ • i

b low e horizorta] iVi^i 'fJt^-plane, 2SI Chicago Datum I M i i m - ' . I " •

|?PR0JEG1i;SITE;-.

RANDOLP.H ST

PARKING

RESIDENTI L

WASHINGTON] S"

OFFICE OFFICE

OFFICE

OFFICE OFFICE

OFFICE

OFFICE RESIDENTIAL

Gross Site Area: 99,856.69 SF (2.29 acres)

Area of Public Riglits-of-Way: 34,474.69 SF (0.79 acres) Net Site Area: 65,382 SF (1.50 acres)

~r~r

NOT TO SCALE 0 60 100

Applicant: 130 North Franklin Development, LLC Address: 130 N Franklin Street, Chicago, IL 60606 Date Introduced: May 20, 2015 Plan Commission:

KRUECK • SEXTON 221 West Erie Street, Chicago, IL

PROPERTY LINE AND PLANNED DEVELOPMENT BOUNDARY MAP

CrriCAGO RIVER

• PD Boundary Line ' Property Line • Dedicated Alley Belovi 29' CCD

ii-' •Ii:

'"oT.ss'.";""!

Dedicated Alley, t alow a horizontBl _

plane, 28 0 feet | | ^

Si^iiPROJECTiSITE-^

••oo

ill I I «1617' I

RANDOL=H ST

W.ASHINGTON ST

rvlADISON ST

I Gross Site Area: 99,856.69 SF (2.29 acres) Area of Public Rights-of-Way: 34,474.69 SF (0 79 acres) Net Site Area: 65,382 SF (1.50 acres)

! I

NOT TO SCALE ^ 0 50 100



EXISTING ZONING MAP

596

• PD Boundary Line ' Property Line • Dedicated Alley Belov/ 29' CCD

PROJECT SITE NOT TO SCALE 0 50 100


KRUECK "SEXTON 221 West Erie Street, Chicago, IL

SITE PLAN RANDOLPH

TOWER

<

o

. / i \

-64'-5-WASHINGTON

9r-5"- -5'9"


NOT TO SCALE ^


LANDSCAPE PLAN I W FiANDOLPH STREET

TREE COUNT STREET TREES REQUIRED 28 per City Ordinance

PLAZA TREES REQUIRED 9 per Plaza Bonus

TOTAL REQUIRED

TOTAL PROPOSED

NOTE: BOTH PERMANENT AND TEMPORARY SEATING TO BE PROVIDED IN PLAZA

PLANT LIST CANOPY TREE | SPECIES TO BE CONSIDERED Ulmus americana (HYBRID ELMS) Ginkgo biloba{G\HKGO) \ Gleditsia triacar thos (HONEYLOCUST) Gymnocladus dioicusp*: • S ^ (KENTUCKY COFFEETREE): * Platanus x acerfolia (LONDON PLANE TREE) Quercus bicolor (SWAMP WHITE OAK) Quercus macrocarpa (BURR OAK) Liriodendron tulipifera (TULIP TREE) Liquidambar styraciflua (SWEETGUM)

UNDERSTORY TREE SPECIES TO BE CONSIDERED /Acer g/nna/a (AMUR MAPLE) Amelanchier lavevis (SERVICEBERRY) Cercis canadensis (EASTERN REDBUD)' Betula nigra (RIVER BIRCH - multistem) Carpinus carolinianasig^- # (AMERICAN HORNBEAM) Comus florida (FLOWERING DOGWOOD) Syringa reticulata (JAPANESE TREE LILAC)

CONCRETE PAVING

SHRUB AND GROUNDCOVER PLANTING

UNDERSTORY TREE

EXISTING HYDRANT TO REMAIN

STONE UNIT PAVER

STONE UNIT PAVER

STREET LIGHTING, TYP.

PROPERTY LINE

W WASHINGTON STREET

Applicant: Address: Date Introduced-Plan Commission:

130 North Franklin Development, LLC 130 N Franklin Street, Chicago, IL 60606 May 20, 2015

CANOPY TREE

CURB CUTS, TYP.

TREE GRATES, TYP.

NOT TO SCALE


GREEN ROOF PLAN

I WFfANDOLPH STREET

PLANT LIST

CANOPY TREE SEE LANDSCAPE PLAN

UNDERSTORY TREE: SEE LANDSCAPE PLAN:

1 1 1 1 L

Ii

-SHRUB & GROUND COVER PLANTING

UNDERSTORY TREE

- CANOPY TREE

- UNIT PAVER

- HEDGE PLANTING

GROUND COVER PLANTING

I ILl LU

Q:

z <

W WASHINGTON STREET"


NOT TO SCALE


ROOF PLAN

ROOF AREA SUMMARY NET ROOF 60% NET ROOF

AREA AREA

LEVELS 21,724 sf 10,862 sf

LEVEL 64 18,747 sf 9,374 sf

TOTAL 40,471 sf 20,236 sf


NOT TO SCALE 1 ^


ELEVATIONS

NOT TO SCALE



ELEVATIONS

_METAL OVERHEAD DOORS

ALL GLASS "CURTAINWALL

METAL OVERHEAD DOORS

ALL Q\J<.SS •'CURTAI JWALL

NOT TO SCALE



SECTIONS

t l o D d i Z I D ! .

^nbndrnnE"

Dpi=Hi=iE

0 LONGITUDINAL SECTION

HEIGHT = 720'-0" BOTTOI OF TOP FLOOR JOIST

16 Floors/High Rise

I I

0 CROSS SECTION

NOT TO SCALE

Applicant: Address: Date Introduced: Plan Commission:

130 North Franklin Development, LLC 130 N Franklin Street, Chicago, IL 60606 May 20, 2015


ij—r«'p5f;. GRAPHIC SCALE GREMLEY A BIEDERMANN

P L C S Corvo rw i Jon

Plat of Survey

- J U ' - ' i . HhL ^ - ' ^ - l . - f ; ' ! —j<

^ _ h - ^ .

A» l,'ll I ( , , I

—

• - — - r T J T - - " - ^ ~~- -*g** -yJ ' - *^ -^ s iT i . . r . ~ " : -w

X -

•:-y\i

— I - ti:?! i; i f-T

H 8i- -i f|=l I

1—S»--_

! IS

• . 4 • -•• .. ' .^ B . «

"••.'KM-

^ ; r

A--.

/ I

• —/•• - i"

/

6<?

i l .

r.. » 1.' 3 , 'l

7q:jl_

4 • ;l

; I

I <

; iii ' f I; I

• I i

11 \- ! I '/f ill : ; i . ' I /

ii [' !rj i ! il

.'. ' ' I

II; i I l; \\ ,'

: 1 1

3Jp II .11 r1l !1 U

i []=••-

E E i t3 !

2015-20363-001 hiTTtrj l» '

- —- * ' — • r - , ' ' . > i J."- J- • • I

4^ I S3 8 /

CITY OF CHICAGO

APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE

1. ADDRESS of the property Applicant is seeking to re2X)ne:

130 North Franklin Street. Chicago. Illinois 60606

2. Ward Number that property is located in: 42nd Ward

3. APPLICANT 130 North Franldin Development. L.L.C.

ADDRESS 45 Rockefeller Plaza

CITY New York STATE NY ZIP CODE 10111

PHONE 312-669-8106 CONTACT PERSON Patrick Kearney

Is the applicant the owner of the property? YES NO X If the applicant is not the owner of the property, please provide the followmg information regarding the owner and attach written authorization from the owner allowing the applicant to proceed.

OWNER Henry Crown & Company d/b/a CC Lidustries

ADDRESS 222 North LaSalle Street

CITY Chicago STATE IL ZIP CODE 60601

PHONE 312-750-6576 CONTACT PERSON Michael Bialas

If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:

ATTORNEY Richard F. Klawiter & Katie Jahnke Dale - DLA Piper LLP (US^

ADDRES S 203 N. LaSalle Street. Suite 1900


PHONE (312)368-7243 /-2153 FAX (312) 630-7337

EMAIL [email protected] / [email protected]

EAST\97625261.2

If the applicant is a legal entitj' (Corporation, LLC, Partnership, etc.) please provide tlie names of all owners as disclosed on the Economic Disclosure Statements: See attached Economic Disclosure Statements

7. On what date did the ovmer acquire legal title to the subject property? Various dates between 1948

and 1980

8. Has the present owner previously rezoned this property? If yes, when? Yes: November 2004

9. • Present Zoning District DC-16 Downtown Core District

Proposed Zoning District Business Plaimed Development

10. Lot size in square feet (or dimensions) +/- 65.382 square feet

11. Current Use of the Property Surface parking and vacant land

12. Reason for rezoning the property To allow for construction of a 53-storv building containing

approximately 1.363.360 square feet of office space: 14.000 square feet of retail and 140 accessory

and non-accessory parking spaces and accessory and incidental uses.

13. Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC)

The Applicant requests a rezoning of the subject property jfrom the DC-16 Downtown Core District and to Business Planned Development to allow for construction of a 53-story building containing approximately 1.363.360 square feet of office space: 14.000 square feet of retail and 140 accessory and non-accessory parking spaces and accessory and incidental uses.

14. On May 14"", 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See fact Sheet for more information)

YES NO X

EAST\97625261.2

COUNTY OF NeA;u\wk STATE OF f^t u^^jVl-

4 ilY.Wii'l 6- i\/'f>r)^,'Lj authorized signatory of 130 North Franklin Development, L.L.C, being first duly sworn on oath, states that all of the above statements and the statements contained in the documents submitted herewith are true and correct.

Subscribed and Sworn to before me this day of M T A J U ,2015.

Signature of Applicant

KERRI A. GARRETT IMaiy PidHic, State o( N«w Itak

NO.01GA6022001 OuaBllsd hi Queens County

OMtlflcate Filed In New Vbrtc County Oommisslon Explrw Much 22,2019

For Office Use Only

Date of Introduction:.

File Number:

Ward:

EAST\9762526L2

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION I GENERAL INFORMATION

A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:

130 North Franklin Development, LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. [x] the Applicant

OR 2. [ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Dis.closing Party holds an interest: OR

3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 45 Rockefeller Plaza

New York, NY 10111

C Telephone- 312-669-8109 Fax" Email" [email protected]

D. Name of contact person: Patrick Kearney

E. Federal Employer Identification No. (if you have one):

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

Zoning amendment application for property at 130 North Franklin Street

G. Which City agency or department is requesting this ED S? Department of Planning and Development

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Ver. 01-01-12 Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A, NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party: ] Person [x] Limited liability company ] Publicly registered business corporation [ ] Limited liability partnership ] Privately held business corporation [ ] Joint venture ] Sole proprietorship [ ] Not-for-profit corporation ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? ] Limited partnership [ ] Yes [ ] No ] Trust [ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, i f applicable:

Delaware

3. • For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [x] No [ ] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

I f the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title See attachment A

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address

Jerry I. Speyer 45 Rockefeller Plaza, New York, NY 10111

Percentage Interest in the Disclosing Party

50%

Robert J. Speyer 45 Rockefeller Plaza, New York, NY 10111 50%

SECTION I I I ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes W No

I f yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):

SECTION IV ~ DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

I f the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE: to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response. DLA Piper LLP (US) - Retained 203 North LaSalle, Suite 1900, Chicago, IL Attomey $10,000 (est)

Kruek & Sexton - Retained 221 East Erie Street, Chicago, IL Architect $25,000 (est)

(Add sheets i f necessary)

[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.

SECTION V ~ CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.

Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ ] Yes [X] No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.

I f "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

[ ] Yes [ ] No

B. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities identified in Section I I .B . l . of this EDS:

a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;

b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;

c. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;

d. have not, within a five-year period preceding the date of this EDS, had one or more public transactions (federal, state or local) terminated for cause or default; and

e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.

3. The certifications in subparts 3, 4 and 5 concern:

• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in

connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or

c. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.

5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.

6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.

7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it wil l be conclusively presumed that the Disclosing Party certified to the above statements.

8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").

N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Party certifies that the Disclosing Party (check one)

[ ] is M is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.

2. I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them wil l become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary):

Page 7 of 13


D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.

1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ] Yes W No

NOTE: I f you checked "Yes" to Item D. I . , proceed to Items D.2. and D.3. I f you checked "No" to Item D. I . , proceed to Part E.

2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

3. I f you checked "Yes" to Item D. I . , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:

Name Business Address Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either 1. or 2. below. I f the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable by the City.

_^ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following .constitutes ful l disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI ~ CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS

NOTE: I f the Matter is federally funded, complete this Section VI . I f the Matter is not federally funded, proceed to Section VI I . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding,

A. CERTIFICATION REGARDING LOBBYING

I . List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it wil l be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and wil l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above.

4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

I f the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

I f "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ]Yes [ ] N o

3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ ] No

I f you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS wil l become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

C. I f the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F. l . The Disclosing Party is not delinquent in the pajmient of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F . l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F. l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date famished to the City.

130 North Franklin Development, LLC

(Print or type name of Disclosing Party)

By: V |'<^XaL^^^^e^rs^c^ (Sign here)

Michael B. Benner Vice President & Secretary

(Print or type name of person signing)

(Print or type title of person signing)

Signed and sworn to before me on (date) fY](Ui , 610 I , at N i ^ ^ County, / V ^ / A , U>/K (sMte).

Commission expires:_

|©1RJA.GARRErr .IMHy Publlo. State of New Vbik

Notary Public. ^ "' QuaiHied in Queens Cotmly

Ccflfflcate Hied in New ^ S ^ ^ CommlBSlon Explie* Mareh 22.2019

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "AppUcable Party" or any Spouse or Domestic Partner thereof currently has a "famihal relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section H.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited UabiUty company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ ] Yes [X] No

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a famiUal relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Mimicipal Code?

[ ]Yes [xJNo

2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ ]Ycs [ ]No [x ] Not Applicable

I f yes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS EVCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

SCHEDULE A

Full names and titles of all executive officers of Disclosing Party:

Chairman and Co-Chief Executive Officer Jerry I. Speyer

Co-Chief Executive Officer and President Robert J. Speyer

Senior Managing Directors Katherine G. Farley

Paul A. Galiano

Michael P.M. Spies

Steven R. Wechsler

Vice President Secretary Michael B. Benner

Vice President Assistant Secretary David Augarten

Vice President Treasurer Russell Makowsky

Assistant Treasurer Victor Cuciniello

C I T Y OF CHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION I -- G E N E R A L INFORMATION

A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable: James Schine Crown, as sole beneficiary of the James Schine Crown Trust, a 8.69% owner of Henry Crown and Company d/b/a CC Industries (the owner)


Indicate whether the Disclosing Party submitting this EDS is: 1. [ ] the Applicant


Applicant in which the Disclosing Party holds an interest: OR

3. a legal entity with a right of control (see Section II.B.l .) State the legal name of the entity in which the Disclosing Party holds a right of control: Henry Crown and Company d/b/a CC Industries

B. Business address of the Disclosing Party: 222 North LaSalle Street

Chicago, I I 60601

C. Telephone: 312.750.6576 Fax: 312.395.7090 Email: [email protected]

D. Name of contact person: Michael Bialas ^



Zoning amendment application flor property at 130 North Franklin Street

G. Which City agency or department is requesting this EDS? Department of Planning and Development

I f the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:


Ver. 01-01-12 Page 1 of 13

SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

Person [ ] Limited liability company [ ] Publicly registered business corporation [ ] Limited liability partnership [ ] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)


3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [ ] No N/A


1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).


Name Title

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.

Page 2 of 13


Name Business Address Percentage Interest in the Disclosing Party

SECTION III - BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D OFFICIALS


[]Yes [fNo


SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES




Page 3 of 13


not an acceptable response.



SECTION V - CERTIFICATIONS




[ ] Yes [)^ No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] No


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article l")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13










Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation; interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;

• any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13










N/A

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it will be conclu.sively presumed that the Disclosing Party certified to the above statements.


None


NOQB



[ ] is [:J is not



"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."


Page 7 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.




[ ]Yes [^[No

NOTE: I f you checked "Yes" to Item D. I . , proceed to Items D.2. and D.3. I f you checked "No" to Item D. l . , proceed to Part E.



[ ]Yes fcINo

3. I f you checked "Yes" to Item D.L, provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:





Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS

NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section VI I . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.


I . List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13





If the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.


[ ] Yes [ ] No

If "Yes," answer the three questions below:


[ ]Yes [ ] N o


[ ] Yes [ ] No


[ ] Yes [ ] No

If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE


A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all stamtes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.ore/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.






Page 11 of 13

F. l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.



NOTE: I f the Disclosing Party cannot certify as to any of the items in F. 1., F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City. James Schiiia--CfowiO as saie beneficiary of the James Schine Crown Trust, a 8.69,2 -6wner ofyflenrY/<3rowii/and Company d/b/a CC Industries (the owner)

'iPrint or type name of person signing)


Signed and sworn to before me on (datey yg</) / 3». ^ / T fS (Estate). ^ O O ^ County j ^ C / ^ ( ? / . S

^ X A ^ ' ^ d j / ^ Notary Public.

Commission expires: /Q

OFFICIAL SEAL' SHARON E. GORDON

NOTARY PUBLIC, STATE OF ILLINOIS ' My Commission Expires Oct 27,2017

Page 12 of 13


APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently have a "familial relationship" with an elected city official or department head?

[ ] Yes [x] No

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B



1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ ]Yes [KJNo

2. I f the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ ] Yes [ i No [ ] Not Applicable

3. If yes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUB.IECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

C I T Y O F C H I C A G O E C O N O M I C D I S C L O S U R E S T A T E M E N T

AND A F F I D A V I T

S E C T I O N I - G E N E R A L I N F O R M A T I O N


Henry Crown and Company d/b/a CC I n d u s t r i e s

Check O N E of the following three boxes:




3. a legal entity with a right of control (see Section I I . B . l . ) State the legal name of the entity in which the Disclosing Party holds a right of control: Henry Crown and Company d/b/a CC Indus t r i e s


Chicago, I L 60601

C. Telephone: 312.750.6576 Fax: 312.395.7090 Email: [email protected]

D. Name of contact person: Michael Bialas

E. Federal Employer Identification No. ( i f you have one): '

F. Brief description o f contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

Zoning amendment a p p l i c a t i o n f o r p roper ty at 130 North F r a n k l i n Street




Ver. 01-01-12 Page 1 of 13

SECTION II - D I S C L O S U R E OF OWNERSHIP INTERESTS


1. Indicate the nature of the Disclosing Party: [ ] Person [ ] Limited liability company [ ] Publicly registered business corporation [ ] Limited liability partnership [J§ Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] N o [ ] Trust [ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporafion or organization, i f applicable:

Delaware


[X] Yes [ ] No [ ] N/A


1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal tit!eholder(s).


Name Title See Exhibit "A" attached hereto


Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional informadon from any applicant which is reasonably intended to achieve full disclosure.


See Exhibit "B" attached hereto

SECTION III - BUSINESS RELATIONSHIPS WITH CITY E L E C T E D O F F I C I A L S


[ ] Yes k] No

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s):





Page 3 of 13

Name (indicate whether Business retained or anticipated Address to be retained)

Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.)

Fees (indicate whether paid or estimated.) NOTE: "hourly rate" or "t.b.d." is not an acceptable response.






Has any person who directly or indirectly owns \ 0% or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ ] Yes Ix] No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ]Yes [ ] N o


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section I I .B . l . of this EDS:


b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust stamtes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;




3. The certifications in subparts 3, 4 and 5 concem:



Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;


Page 5 of 13










Page 6 of 13



None




[ ] is ^ ] is not





Page 7 of 13





[ ] Yes y No

NOTE: I f you checked "Yes" to Item D. l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D. l . , proceed to Part E.

2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensafion for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.


[ ] Yes y No






Page 8 of 13




SECTION VI -- CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS



1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets if necessary):

N/A



Page 9 of 13







[ ]Yes [ ] N o



[ ]Yes [ ] N o


[ ]Yes [ ] N o


[ ]Yes [ ] N o


Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE


A. The cerfifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N.






Page 11 of 13




NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

Henry C /a CC Indus t r i e s



Signed and sworn to before me on (date) i^v^<><>i>3>^/^ at __i3ieit County, XLi^/ni),^ {site)

Notary Public.

Commission expires: f J i l

« "OFFICIAL SEAL" . SHARON E. GORDON < NOTARY PUBLIC. STATE OF ILLINOIS < My Commission Expires Oct 27,2017 i ^ < i i i « m i i » » w « i i > i j i ' U P «

Page 12 of 13


APPENDIX A




"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes [ ] No


Page 13 of 13


APPENDIX B




[ ]Yes [X]No


[ ] Yes i i No [ ] Not Applicable

If yes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.


AND AFFIDAVIT

SECTION I - G E N E R A L INFORMATION

A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable: Arie Steven Crown, as sole beneficiary of the Arie Steven Crown Trust, a 17.84% owner of Henry Crown and Company d/b/a CC Industries (the owner)


Indicate whether the Disclosing Party submitting this EDS is: 1. [ ] the Applrcant



3. [}j a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control: Henry Crown and Company dl^b/a CC Industries


Chicago, IL 60601

C. Telephone: 312.750.6576 Fax: 312.395.7090 Email: mbialasPcrown-phiragn.rnni

D. Name of contact person: Michael Bialas


F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and locafion of property, i f applicable):

Zoning amendment application fo r property at 130 North Franklin Street




Ver. 01-01-12 Page 1 of 13







[ ] Yes [ ] No M N/A


1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal fitleholder(s).


Name Title

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venmre.

Page 2 of 13



SECTION III -- BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D OFFICIALS


[ ]Yes [ | : N O






Page 3 of 13










[ ]Yes [x] No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compliance with that agreement?

[ ] Yes [ ] No


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13











• any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Enfity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13






4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotadng in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.




N/A

Page 6 of 13



None


None



[ ] is [}3 is not





Page 7 of 13





[ ] Yes [x\ No

NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D. l . , proceed to Part E.



[ ] Yes bd No






Page 8 of 13





NOTE: I f the Matter is federally funded, complete this Section VI . I f the Matter is not federally funded, proceed to Section VI I . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.





Page 9 of 13







[ ]Yes [ ] N o



[ ] Yes [ ] No


[ ] Yes [ ] No


[ ] Yes [ ] No

I f you checked "No" to question I . or 2. above, please provide an explanation:

Page 10 of 13



A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N.


C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.




Page 11 of 13

F.l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Enfities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.


F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.


CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City. Arie Steven Crown, as sole beneficiary of the Arie Steven Crown Trust, a 17.84% owner of Henry Crown and Company d/b/a CC Industries (the owner)

(Print or type name of Disîîng Party)

(Sign here)

Arie Steven Crown (Print or type name of person signing)


Signed and sworn to before me on (date) at C^QO 1^ County, Ûi.

i t e ) ^ ^ t L ^ I fUQi"^' (stafe).

Commission expires: ^

1^ AofS

Notary Public.

r ~ •*• ^ OFFICIAL SEAL'

SHARON E. GORDON NOTARY PUBLIC, STATE OF ILUNOIS

My Commission Expires Oct 27,2017 _1 . m •!> Bi M II • I • •

Page 12 of 13


APPENDIX A




"Applicable Party" means (1) all executive officers of the Disclosing Party listed m Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes [jd No


Page 13 of 13


APPENDIX B




[ ]Yes [X]No


[ ]Yes [ jNo [ ] Not Applicable



Exhibit "A"

Executive Officers and Directors of Henry Crown and Company

Officers:

Lester Crown Charles H. Goodman James S. Crown William H. Crown

A. Steven Crown William C. Kunkier, III Michael S. Canmann Ryan Stewart James A. Star Richard H. Robb Kirk Rose David M. Rubin Rahul Danak Mark Hoffman Joy Schaum Maureen Flynn Michael Podgorski James Biegel Brian B. Gilbert Marvin Bailey, Sr. Daniel Dahlberg Dan Crown

Chairman Vice Chairman President

Vice President, President/Chief Executive Officer of CC Industries Inc. Division, Executive Vice President and Chief Financial Officer Vice President Vice President - Operations Executive Vice President and Chief Financial Officer Vice President Vice President Vice President Senior Vice President - Tax and Accounting Vice President - General Counsel and Secretary

Vice President - Accounting & Corporate Controller of CC Industries, Inc. Division Vice President - Information Systems and Technology Vice President - Tax Planning Vice President - Accounting & Corporate Controller of CC Industries, Inc. Division Treasurer Vice President-Tax and Compliance Assistant Secretary Vice President-Land Development Vice President-Community Relations Vice President

Directors:

Lester Crown Charles H. Goodman James S. Crown William H. Crown A. Steven Crown

4835-1442-9471, V. 1

EXHIBIT B

Rebecca Eileen Crown Trust

Arie Steven Crowu Trust

James .Schine Crown Trust

Daniel Morris Crown Trust

Nancy Jean Crowi Trust

Patricia Ann Crown Trust

14.05% owner

17.84% owner

8.69% owner

5.16% owner

5.75% owner

5.16% owner

City of Chicago



02015-4175

Meeting Date:

Sponsor(s):

Type:

Title:

Committee(s) Assignment:

5/20/2015

City Clerk (transmitted by)

Ordinance

Zoning Reclassification Map No. 7-F at 506-514 W DIversey Ave-App No. 18382 Committee on Zoning, Landmarks and Building Standards

//vJ-tfT-o P A T H S '

ORDINANCE

BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:

SECTION 1. That the Chicago Zoning Ordinance be amended by changing all of the B3-5 Community Shopping District symbols and indications as shown on Map 7-F in the area bounded by:

West DIversey Parkway; a line approximately 82.00 feet west of and parallel to North Pine Grove Avenue; the public alley next north of and parallel to West Diversey Parkway and a line approximately 182.00 feet west of and parallel to North Pine Grove Avenue;

to those of a Residential-Business Planned Development.

SECTION 2. This Ordinance shall be in force and effect from and after its passage.

Applicant: Broder Diversey LLC Address: 506-514 West Diversey Parkway, Chicago, Illinois Introduced: May 20, 2015 Plan Cominission: TBD EASn96963799.2

RESIDENTIAL-BUSINESS PLANNED DEVELOPMENT NO.

PLANNED DEVELOPMENT STATEMENTS

1. The area delineated herein as Planned Development Number ("Planned Development") consists of approximately 15,000 net square feet of property which is depicted on the attached Planned Development Boundary and Property Line Map ("Property"). Broder Diversey LLC is the owner of Subarea A and the Applicant for this Planned Development, with the consent of the owner of Subarea B.

2. The requirements, obligations and conditions contained within this Planned Development shall be binding upon the Applicant, its successors and assigns and, i f different than the Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to the requirements of Section 17-8-0400 of the Chicago Zoning Ordinance, the Property, at the time of application for amendments, modifications or changes (administrative, legislative or otherwise) to this Planned Development are made, shall be under single ownership or designated control. Single designated control is defined in Section 17-8-0400 of the Zoning Ordinance in effect as of the date of this Planned Development.



Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Chicago Department of Planning and Development ("DPD") and CDOT. Closure of all or any public street or alley during demolition or construction shall be subject to the review and approval of CDOT.

All work proposed in the public way must be designed and constructed in accordance with CDOT Construction Standards for Work in the Public Way and in compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by CDOT.

4. This Plan of Development consists of these 15 Statements, a Bulk Regulations and Data Table, and the following exhibits and plans prepared by PappageorgeHaymes Partners, Ltd. and dated , 2015 (collectively, the "Plans"): an Existing Zoning Map; an

Applicant: Broder Diversey LLC Address: 506-514 West Diversey Parkway, Chicago, Illinois Introduced: May 20, 2015 Plan Commission: TBD EAST\96963799.2

Existing Land Use Map; Planned Development Boundary and Property Line Map; Site Plan; Landscape Plan; Green Roof Plan; and Building Elevations. Full-sized copies of the Plans are on file with the DPD. In any instance where a provision of this Planned Development conflicts with the Chicago Building Code, the Building Code shall control. This Planned Development conforms to the intent and purpose of the Zoning Ordinance, and all requirements thereof, and satisfies the established criteria for approval as a Planned Development. In case of a conflict between the terms of this Planned Development Ordinance and the Zoning Ordinance, this Planned Development Ordinance shall control.

5. The following uses shall be permitted in this Planned Development: All uses allowed in the B3-5 Community Shopping District, including Dwelling Units located above and on the ground floor; Eating and Drinking Establishments; Retail Sales, General; and accessory parking.



8. The maximum permitted Floor Area Ratio ("FAR") for the Property shall be in accordance with the attached Bulk Regulations and Data Table. For the purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted overall FAR identified in the Bulk Regulations Table has been determined using a Net Site Area of 15,000 square feet. In the event that the existing improvements in Subarea B are destroyed or significantly damaged, such improvements may be rebuilt provided they are in compliance with the limitations set forth herein.

9. Upon review and determination, "Part II Review", pursuant to Section 17-13-0610 of the Zoning Ordinance, a Part II Review Fee shall be assessed by DPD. The fee, as determined by staff at the time, is final and binding on the Applicant and must be paid to the Department of Revenue prior to the issuance of any Part II approval.

10. The Plans shall be in substantial conformance with the Landscape Ordinance and any other cortesponding regulations and guidelines. Final landscape plan review and approval will be by DPD. Any interim reviews associated with site plan review or Part II reviews, are conditional until final Part II approval.

11. The Applicant shall comply with Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation, Fleet and Facility Management and Buildings, under Section 13-32-125 of the Municipal Code, or any other applicable provision of that Code.

Applicant: Broder Diversey LLC Address: 506-514 West Diversey Parkway, Chicago, Illinois Introduced: May 20, 2015 Plan Commission: TBD EAST\96963799.2

12. The terms and conditions of development under this Planned Development Ordinance may be modified administratively, pursuant to section 17-13-0611-A of the Zoning Ordinance, by the Zoning Administrator upon the application for such a modification by the Applicant, its successors or assigns and, if different than the Applicant, the legal title holders and any ground lessees of the Property.


14. The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resources. The Applicant shall seek LEED certification, and provide a green roof of not less than 50% of the net roof area equivalent to an actual total of square feet in Subarea A.

15. This Planned Development shall be governed by Section 17-13-0612 of the Zoning Ordinance. Should this Planned Development Ordinance lapse, the Commissioner of DPD shall initiate a Zoning Map Amendment to rezone the property to the B3-5 Community Shopping District.

Applicant: Broder Diversey LLC Address: 506-514 West Diversey Parkway, Chicago, Illinois Introduced: May 20, 2015 Plan Commission: TBD BAS-n96963799 2

RESIDENTIAL-BUSINESS PLANNED DEVELOPMENT NO. BULK REGULATIONS AND DATA TABLE

Gross Site Area (sf):

Area of Public Rights-of-Way (sf):

Net Site Area (sf):

Maximum Floor Area Ratio:

Maximum Number of Dwelling Units:

Minimum Off-Street Parking Spaces:

Minimum Off-Street Loading Spaces:

Maximum Building Height:

Minimum Setbacks:

Sub-Area A

14,250

3,000

11,250

6.3

53

53

1

Per elevations

Per plans

Sub-Area B

4,750

1,000

3,750

1.4

3

0

0

Applicant: Broder Diversey LLC Address: 506-514 West Diversey Parkway, Chicago, Illinois Introduced: May 20, 2015 Plan Commission: TBD nAS'R96963799.2

AUTHORIZATION

The undersigned, LA COMMERCIAL, L.L.C, a Colorado limited liabiiiiy company, being the owner of real properly located generally at 506 West Diversey in Chicago, Illinois (collectively, the "Subject Property"'), hereby authorizes BRODER DIVERSEY LLC. a Delaware limited liability company, and any aftlliate or designee thereof and its attorneys. DLA Piper LLP (US), to file one or more applications for a planned development, review pursuant to the Lake Michigan and Chicago Lakefront Protection Ordinance and other zoning approvals and related permits and approvals with the City of Chicago relating to the Subject Property.

Notwithstanding anything contained herein the contrary, the foregoing authorization of L.A Commercial. L.L.C. is hereby given only with respect to the submission of the Application for an Amendment lo the Chicago Zoning Ordinance in the form that is attached, with all exhibits thereto. Any revision to the attached Application or the exhibits thereto or any request for any other approvals or permits that affect Subarea B shall require a new authorization from LA Commercial. L.L.C.

IN WITNESS WHEREOF, the undersigned has executed this Authorization as of this XL^day of May, 2015.

LA COMMEaClAL_L.L.C

By: (^^akevi

^y

I ASI"\%4hl754 I

n KDLA PIPER

DLA Piper LLP (US) 203 North LaSalle Street, Suite 1900 Chicago, Illinois 60601-1293 www.dlapiper.com

Katherine C. Jahnke Dale [email protected] T 312.368.2153 F 312.251.2856

May 13, 2015

The Honorable Daniel Solis, Chairman City of Chicago Committee on Zoning Room 304, City Hall 121 North LaSalle Street Chicago, Illinois 60602


Re: Application for Residentiai-Business Planned Development & Approval Under The Lalce Michigan and Chicago Lai^efront Protection Ordinance Broder Diversey LLC

Dear Chairman Solis and Chairman Cabrera:

The undersigned, Katherine C. Jahnke Dale, an attorney with the law firm of DLA Piper LLP (US), which firm represents Broder Diversey LLC, the applicant for an amendment to the Chicago Zoning Ordinance, proposed planned development and approval under The Lake Michigan and Chicago Lakefront Protection Ordinance, certifies that she has complied with the requirements for Section 17-13-0107 of the Chicago Zoning Ordinance by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet of each direction of the lot line of the subject property, exclusive of public roads, streets, alleys and other public ways. Said written notice was sent by First Class U.S. Mail, no more than 30 days before filing the application.



Very truly yours,

DLA Piper LLP (US)

2015. Subscribed and sworn to before me ThisJilidayof

Public


t -OFFICIAL SEAL" % I ILLIANA RAMOS * * Notary Public, State of Illinois • % Mv Commission Expires 0r/10;20ie»

EASTM 00598007.2


Paul Shadle Paul.shadle@dlapipercom T 312,368.3493 F 312,251.5870

May 13, 2015

FIRST CLASS MAIL

Dear Sir or Madam:

As required by Section 17-13-0107 of the Municipal Code of the City of Chicago, please be informed that on or about May 13, 2015, the undersigned, on behalf of Broder Diversey LLC (the "Applicant"), intends to file applications for a change of zoning for the property located at 506-514 West Diversey Parkway, Chicago, IL 60614 (the "Property") from the B3-5 Community Shopping District to a Residential Business Planned Development and for approval under The Lake Michigan and Chicago Lakefront Protection Ordinance relating to the property located at 508-514 West Diversey (the "Development Site"). A map of the Property is printed on the reverse side of this letter.

The Property is currently utilized as a surface parking lot and an existing three-story commercial/residential building. The Applicant seeks approval of plans to allow for a new approximately 11-story residential building with ground floor retail containing up to 53 dwelling units on the Development Site.

The proposed change of zoning does not apply to your property. You are receiving this notice as required by the Chicago Municipal Code because the Cook County Assessor's records indicate that you own property within 250 feet of the Property.

I am an authorized representative of the Applicant and my address is 203 North LaSalle Street, Suite 1900, Chicago, IL 60601. The Applicant owns the Development Site. The Applicant's address Is 15 Broad Street, Boston, Massachusetts 02109. The remainder of the Property located at 506 West Diversey is owned by LA Commercial, L.L.C, whose address is 65 E. Wacker Place, Suite 2300 Chicago, Illinois 60661.


Very truly yours,

Piper LLP (US)

Paul Shadle

EAST\100597861.2

pappageorgehaymes partners architect

640 N LaSalle. Suite 400 Chicago, IL 60654 312 337 3344 FAX 204 8988

Applicant: Broder D iversey L L C

Address: 506-514 West Diversey Parkway Chicago, IL 60614

Introduction date: May 20th, 2015 I Plan commission date: TBD

Existing Zoning iVIap

Scale. 1 0 64 ®

Existing 3-Story Residential

Building Existing 1-Sto|y

Qarage


Building

Existing 1-Sto^ Garage


Building I—

14' Public Alley 100.00'

<

75'-0" Sub-Area A

25'-0" Sub-Area B


Building

Project Site

Existing 3-Story

Residential Building

Existing 3 Story

lesldentia Building


Building

roooo' • • •

W. Diversey Parltway

Existing 1-Story Commercial

Building

Existing 11-Story

Residential Building


640 N LaSalle, Suite 400 Chicago, IL 60654 312 337 3344 FAX 204 8988

Applicant Broder Diversey LLC


j Introduction date May 20th, 2015 1 Plan commission date: TBD

Existing Land Use IVlap

Scale. 1" =50'


Building —w— _ ^ —

ISr 100.00'

75'-0" Sub Area A

25-0"

o o

Sub Area B


Building

Project Site

Property ' Line


Building


Building

100.00'

• • • W. Diversey Parkway

Planned Development ' Boundary J go

Gross Site Area: IQ.OOOsf Area in Riglit-of-Way: 4,000sf

Net Site Area: 15,000sf

i pappageorgehaymes partners architect


I Applicant: B r o d e r D i v e r s e y L L C


. Introduction date: May 20th, 2015 : Plan commission date: TBD

Planned Development Boundary and Property Line Map Scale. 1" = 30' ®



Applicant' Broder D iversey L L C

Address' 506-514 West Diversey Parkway Chicago, IL 60614

Introduction date May 20th, 2015 Plan commission date TBD

Site Plan

Scale 1" =20 '

South Elevation

P P Q P P n n n n n

- Profiled Alum Slab Edge

-Alum Windows

- Glass Balcony Railing

- Open To Garage

B m B B B ffi B B B ffl B a

B B ffl B B B BB B B B ffl B

Noilh Elevation


840 N. LaSalle, Suite 400 Chicago, IL 60654 312 337 3344 FAX 204 8988

Applicant: Broder DIversey L L C

Address' 506-514 West Diversey Parkway Chicago. IL 60514

Introduction date' May 20th, 2015 Plan commission date TBD

North and South Elevations

Scale 1" =50 '

Alum + Glass Window System

Fire-Rated Windows

Line of Adjacent Building

Stone Wall Panel System

Glass Canopy

/ W. D i v e r s e y r ^5 } Parkway *

Alum Windows

Architectural Precast Concrete Panels S ' Courtyard

Stone Wall Panel System

Glass Balcony Railing

FIra-Ratcd Windows

Alum + Glass Window System

Allpy

East Elevation

West Elevation


640 N LaSalle. Suite 400 Chicago, IL 60654 312 337 3344 FAX 204 8£

Applicant:

Address

Broder DIversey L L C

506-514 West Diversey Parkway Chicago, IL 60614

Introduction date May 20th, 2015 Plan commission date' TBD

East and West Elevations

Scale-1" =50 '

\

% Green

Net Roof Area: 8,574 sf Green Roof Area: 4,287 sf

Roof Provided: 50%



Applicant: B r o d e r D i v e r s e y L L C

Address' 506-514 West Diversey Parkway Chicago, IL 60614

Introduct ion date M a y 2 0 t h , 2015 ! Plan commission date TBD

Landscape and Green Roof Plan

Scale. 1" =20 '

I I


K' J. ICv-:;r .''Huvr>4'-"'-v;' 'v: -'''~?;" ^

;^:o,:-

, B l - 5

m

1 ;

1 , • \- -1 - f ••

' ~ . :J\ ' : •• < • ...r.,.-. • \~^x • ' i

> V •: r •

\V''

PINs:

14-28-123-010 TO-013

EAST\100597861.2

GREMLEY & BIEDERMANN PLCS Corporation

U39 H m n ELITW I I T M . CMato iL H630

T i u m i CT7I) Wl-Siaz F i i (7 ; ] ) : ) e - i i U EH* IL INFOWLCS-Swr CM

ALTA/ACSM Land Title Survey SUB AREA A' THE WEST HALF C F LI3T B AMD AU. OF LOT • IN BLOCK 3 IN LEUOTNES SUBOr^lON OF THE SOUTH i t A C K E S o r T > f : E A f f T K u / O F T i C H a f f n w E a T a u A i r E R O F B E C T i O N a . T i 7 i m a H i p 40 NORTH. KAMGE :« EAST OF THE THRO PKNCVAL UERDIW. IN COOK COWfTr LUMSS.

CONTAHNc; x.2sa 9Q FT on D as A C K S S M O R E O R L E S S

S U D A ; ^ V

T H E E A S T H A L F O F L O T » KN 0 I . O C K 3 IH I C Y C T M C ? 3 U D C M 3 I O N O F T H E AOLTTH -.0 A C R C 3 O F

T X EAST HA1.F OF THE NDRTHMCST t X W n C R CF SECTION » , T O T K K P 40 N o m H f V M X 14. CAST OF T>C TKRO PR>C*>AI. UERDWN. IN COOK COWOY LUNOU

COKTAININO 3.T90 s o FT OR 0 OS ACHES UONE CR LESS

GRAPHIC SCALE

A.-AaPHAl.T[ OR ^i lViVB. FLEVATKM FFc.-nM3»C0 FLOOR ELEVAIRM

X - C O W B E T E aEVATlOW TOC.-TOP OF SLOPE ElfVATWH TOB -TO^ OF l A W ELEVATCN

n btan k x a M tan ftarf MM«y WaimaBn

Mnrrni iN. WCMK I « H D u n s iwu]

n.Cl. C a m i r a

2015-20378-001 teTTiTp 1

SURVCf NOTC3

UTILJTY WMNMG

Tlw inivgrDund u J l *

C r i DtCGER - (3:1) 744-7000 m Ctr irf C M c v .

OUMS << t » O y i« CMoago ^ J U L I E. (SOO) N 2 - o m p

PVMI3E3 COVEHEO Br t SNOW UAY CeSOJRE AODmOWi. IWnmEMENTV.

SlWVEYNOTtS

PROPERTY APPEARS N TJTHE^ AREAS" ZCW: X, A U A 9 OCTE.WINED vmEET nODU m . CHI r o BE OUTBlDE THE 0 J % WNIM. ChW4CE FLOOOnjklN FER FLOOD i j i D - T U - W U FOR CEir _ _ WauRAWCE RATE W COCK COUNTY. ILWOW. I * V W) -.7M1CW17J. tfCCIFE IWTTIRS PtP^AinM "t) T>« AWar

' EFFECTTVE DATE AUGUST 11 IDOB K K H l O A n F e A n O N

LOCATUH- IW/ER3EY PARKWAY • PINE GItOVE (HORTTCATT CDRNEH) 4 ' F C E T NORTH OF THE NORTH LI tE OF DIVERSEY PArtWAY, 11 BO FEcT 'ffiST OF THE EAST LI>C OF P K OaCKE

SECONDART SENCntARK • 1 S 4 ELEVATTOh • K O U

LOCATION DEMINS PLACE 1 OnCHARD STREET

91PACE9S OF0EUiNaPLACEAM}4PACES'AE;TOF OnCHARD STREET UAnKO/TONNOR'Tf ENDOFLOMEST 8TGME BTEP AT ENTRAMCE OF 0403 OHCHAfC STREET

i g t f r « e n l « i n i

n b w i a z a i f

CITY OF CHICAGO


1. ADDRESS of the property Applicant is seeking to rezone:

506-514 West Diversey Parkway

2. Ward Number that property is located in: 44th Ward

3. APPLICANT Broder Diversey LLC

ADDRESS 15 Broad Street

CITY Boston STATE MA ZIP CODE 02109

PHONE (617)292-2009 CONTACT PERSON Mark Kozlowski

4. Is the applicant the owner of the property? YES X NO X_ If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the applicant to proceed. **Note: The applicant owns the property located at 508-514 West Diversey. The following entity owns the property located at 506 West Diversey.

OWNER LA Commercial. L.L.C.

ADDRESS 65 E. Wacker Place. Suite 2300


PHONE 312-460-8870 CONTACT PERSON DayidAufrecht

5. If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoning, please provide the following information:

ATTORNEY DLA Piper LLP CUS). Attn: Paul Shadle & Katie Jahnke Dale

ADDRESS 203 North LaSalle. Suite 1900


PHONE r312) 368-3493 /-2153 FAX 012)251-2856

EMAIL paul.shadle(2),dlapiper.com / katie.daIe(g).dlapiper.com

EAS'R96462205.1

6. If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements:

See attached economic disclosure statements.

7. On what date did the owner acquire legal title to the subject property? November 2014 /July 2013

8. Has the present owner previously rezoned this property? If yes, when? No

9. Present Zoning District B3-5 Community Shopping District

Proposed Zoning District Residential Business Planned Development

10. Lot size in square feet (or dimensions) 15.000 sf

11. Current Use of the Property Commercial/Residential/Surface Parking Lot

12. Reason for rezoning the property To allow for an approximately 11-story residential building with

ground floor retail containing up to 6.3 FAR and up to 53 dwelling units.


The Applicant requests a rezoning of the subject property from the B3-5 Community Shopping District to a Residential Business Planned Development, to allow an approximately 11-story residential building containing up to 6.3 FAR. 53 dwelling units, ground floor retail and accessory uses, as set forth in the enclosed project narrative and plans.

14. On May 14"', 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See fact Sheet for more information) subsequent

YES NO X

EAST\96462205.I

COUNTY OF COOK STATE OF ILLINOIS

n , authorized signatory of Broder Diversey LLC, being first duly sworn on oath, states that all of the above statements and the statements contained in the documents submitted herewith are true and correct.

Subscribed and Sworn to before me this Signature of ARpli^aiit

1)^ day of 2015.

Notai

STEPHEN J. BRADLEY . Notary Public fcOMMONWEALTH OF MASSACHUSETTS

My Commission Expires April 1, 2022

For Office Use Only

Date of Introduction:

File Number:

Ward:

EAST\96462205.1


AND AFFIDAVIT

SECTION 1 - G E N E R A L INFORMATION


Broder Diversey LLC





3. [ ] a legal entity with a right of control (see Section II .B.l . ) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: c /o Broder P r o p e r t i e s LLC

38 Newbury S t r e e t , 3 rd F l , Boston, MA 02116

C. Telephone: (617) 292-2009 Fax: Email: [email protected]

D. Name of contact person: Dana N i e l s e n

E. Federal Employer Identification No. (if you have one): _•


Application f o r Planned Development: 506-514 W. Diversey, Chicago

G. Which City agency or department is requesting this EDS? OV'Q



Ver. 01-01-12 Page 1 of 13




Person [J Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)


Delaware


[ ] Yes [5? No [ ] N/A


I . List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).


Name Title Broder Diversey HV LLC Managing Member


Page 2 of 13


Name Business Address Percentage Interest in the c/o Broder Properties LLC Disclosing Party

Broder Diversey HV LLC 38 Newbury S t r e e t , 3rd F l . 75%

Boston, MA 02116

Mark Kozlowski 1655 W. Wrightwood 25%

Chicago, , I L 60614

SECTION 111 - BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ ] Yes [x] No




"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: ( I ) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney, to be retained) lobbyist, etc.)

DLA Piper LLP 203 N. LaSalle St. Attorney

paid or estimated.) NOTE: "hourly rate" or "t.b.d." is not an acceptable response. $10,000 ( e s t ima te )

Su i te 1900

Chicago, I L 60601







[ ] Yes Ixl No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o


1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article r')(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13












Page 5 of 13










Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.


KlA


KLB,



[ ] is bd is not




If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary):

Page 7 of 13





[ ] Yes [}q No




[JYes y N o

3. I f you checked "Yes" to Item D. l . , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:




Please check either I . or 2. below. I f the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13







1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets i f necessary):



Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . I . and A.2. above.


5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . I . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.




[ ]Yes [ ] N o



[ ]Yes [ ] N o


[ ]Yes [ ] N o


[ ] Yes [ ] No


Page 10 of 13




B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.






Page I I of 13

F.I . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.



NOTE: I f the Disclosing Party cannot certify as to any of the items in F.I . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

C E R T I F I C A T I O N

Under penalty of perjury, the person signing below: ( I ) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

Broder Diversey LLC

(Print or typ^ name of Disclosing Party)

By:_ (Sign here)

Dana Nielsen


Manager


Signed and sworn to before me on (date) _ County, /l/la^^Qokl^sdti (state).

Notary Public.

Commission expires: ^/^|7A/ IjQVU

Page 12 of 13

^ STEPHEN J. BRADLEY Notary Public

COMMONWEALTH OF MASSACHUSEnS My Commission Expires

^ S i j ^ April 1. 2022


APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFFICIALS AND DEPARTMENT HEADS



"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes [X] No


Page 13 of 13


APPENDIX B




[ ]Yes [ x ] N o


[ ] Yes [ ] No [X ] Not Applicable



2798430.1


AND AFFIDAVIT



Broder Diversey HV LLC



OR 2. a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest: Broder Diversey LLC OR


B. Business address of the Disclosing Party: c /o Broder P r o p e r t i e s LLC

38 Newbury Street, 3rd F l , Boston, MA 02116



E. Federal Employer Identification No. (if you have one): N/A


Application f or Planned Development: 506-514 W. Diversey, Chicago

G. Which City agency or department is requesting this EDS?



Ver. 01-01-12 Page I of 13




Person [X] Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)


Delaware


[ ] Yes p] No [ ] N/A

B. JF THE DISCLOSING PARTY IS A LEGAL ENTITY:



Name Title Dana N ie l s en Manager


Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the c/o Broder P r o p e r t i e s Disc los ing Party

.Svenson High V i s t a GRAT 38 Newbury S t r e e t , 3 rd F l . 100%

Boston, MA 02116

SECTION HI -- BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ ] Yes [x] No


SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND O T H E R RETAINED PARTIES




Page 3 of 13





Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.





[ ] Yes [x] No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o


1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13


a. arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;










Page 5 of 13






4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of ( I ) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.



7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13



N/A


N/A



[ ] is y is not





Page 7 of 13

If the letters "NA," the word "None," or no response appears on the Hnes above, it will be conclusively presumed that the Disclosing Party certified to the above statements.




[ ] Yes M No

NOTE: I f you checked "Yes" to Item D. I . , proceed to Items D.2. and D.3. I f you checked "No" to Item D. I . , proceed to Part E.



[ ] Yes ^ ] No






Page 8 of 13


X I . The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.



NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section VI I . For purposes of this Section VI , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.





Page 9 of 13



5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certificafions equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.




[ ] Yes [ ] No



[ ]Yes [ ] N o


[JYes [ ] N o


[ ]Yes [ ] N o


Page 10 of 13

SECTION V I I - - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE





C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.


E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERM ANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page I I of 13



F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.




Broder Diversey HV LLC

(Print or tyge name of Disclosing Party)

By:

or type name or uisciosing f £

(Sign here)

Dana Nielsen


.Manager (Print or type title of person signing)

Signed and sworn to before me on (date) ^ j i l h ^ at ^ M I ^ County, i\ha^](Kk\Ms (state). ~

Commission expires: 1 ), IJ^H^

Notary Public.

Page 12 of 13

tfv S T E P H E N J . BRADLEY Notary Public I

COMMONWEALTH OF MASSACHUSETTS | My Commission Expires

April 1, 2022


APPENDIX A




"Applicable Party" means (I) all executive officers of the Disclosing Party listed in Section U.B.I .a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes [x] No


Page 13 of 13


APPENDIX B




[ J Y e s t x l N o


[ ] Yes [ ] No [x ] Not Applicable



2798429.1


AND AFFIDAVIT

SECTION 1 -- GENERAL INFORMATION


Svenson High V i s t a GRAT



OR 2. a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest: Broder Diversey LLC OR


B. Business address of the Disclosing Party: c /o Broder P rope r t i e s LLC

38 Nev/bury S t r e e t , 3rd F l , Boston, MA 02116





Application f o r Planned Development: 506-514 W. Diversey, Chicago

G. Which City agency or department is requesting this EDS? 'O'^^^



Ver. 01-01-12 Page 1 of 13



1. Indicate the nature of the Disclosing Party: [ ] Person [ ] Limited liability company [ ] Publicly registered business corporation [ ] Limited liability partnership [ ] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] No [X| Trust [ ] Other (please specify)



[ ] Yes [ ] No ^ ] N/A




Name Title John S c h i l l e r Trustee


Page 2 of 13


Name Business Address Percentage Interest in the c/o Broder P r o p e r t i e s Disclosing Party

E r i c Svenson 38 Newbury S t r e e t , 3 rd F l . 33.3%

Boston, MA 02116

Ben Svenson (same address f o r a l l ) 33.3%

Sarah N i e l s e n 33.4%

SECTION III - BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ ] Yes [x] No


SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND O T H E R RETAINED PARTIES


"Lobbyisf means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.


Page 3 of 13





[5 Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.







[ ] Yes [ ] N o



Page 4 of 13












Page 5 of 13


a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a pubhc officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;




4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of ; engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.




Page 6 of 13



N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a " g i f f does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

N/A



[ ] is y is not





Page 7 of 13





[ ] Yes M No

NOTE: I f you checked "Yes" to Item D. l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.



[ ] Yes ^ ] No

3. I f you checked "Yes" to Item D.I . , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:





Page 8 of 13





NOTE: I f the Matter is federally funded, complete this Section VI . I f the Matter is not federally funded, proceed to Section VII . For purposes of this Section VI , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.





Page 9 of 13







[ ]Yes [ ] N o



[ ] Yes [ ] No


[ ]Yes [ ] N o


[ ]Yes [ ] N o


Page 10 of 13

SECTION V I I - - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE



B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.






Page 11 of 13




NOTE: I f the Disclosing Party cannot certify as to any of the items in F.I . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.



Svenson Mi^K Vls-fca G A A T

(Print or tyae name of

By:

sing Party)

(Sign here)


Tc us-i.ee


Signed and sworn to before me on (date) at c )vf j \H County, / I ^ O J J ^ / I A I A (state).

Notary Publi(

^ STEPHEN J. BRADLEY Notary Public

COMMONWEALTH OF MASSACHUSETTS My Commission Expires

April 1. 2022

Commission expires:

Page 12 of 13


APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section H.B.l.a., i f the Disclosing Party is a corporation; all partaers of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partaership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority. -


[ ] Yes Ix] No


Page 13 of 13


APPENDIX B




[ J Y e s [ x ] N o





2798429.1

C I T Y OF C H I C A G O ECONOMIC D I S C L O S U R E STATEMENT


S E C T I O N I - G E N E R A L INFORMATION



Indicate whether the Disclosing Party submitting this EDS is: 1. ^ the Applicciuf !)\)JV\&r



3. [ ] a legal entity with a right of control (see Section II .B. l . ) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: ^"^0 U,' • feslJfe<\

C. Telephone: 173-^35"-QlAO Fax: Email:

D. Name of contact person: lCl<M



G. Which City agency or department is requesting this EDS



Ver. 01-01-12 Page 1 of 13

SECTION II -- DISCLOSURE OF OWNERSHIP I N T E R E S T S


1. Indicate the nature of the Disclosing Party: Person Publicly registered business corporation Privately held business corporation Sole proprietorship General partnership Limited partnership Trust

\ ^ Limited liability company [ ] Limited liability partnership [ ] Joint venture [ ] Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

[JYes [ JNo [ J Other (please specify)



[ J Yes [ JNo M N/A


1. List below the ful l names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).


Name Title


Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve ful l disclosure.




[ J Yes ^ No


SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND O T H E R R E T A I N E D PARTIES




Page 3 of 13





^ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.

SECTION V - C E R T I F I C A T I O N S




[ ] Yes p(f No [ J No person directly or indirectly owns 10% or more of the Disclosing Party.


[ J Yes [JNo


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing biisiness with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13












Page 5 of 13










Page 6 of 13


8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). ^or\£^

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a " g i f f does not include: (i) anj^hing made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.



[ J is 1^ is not





Page 7 of 13





[ ] Yes IX No

NOTE: I f you checked "Yes" to Item D . l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D.L, proceed to Part E.



[ J Yes Dd No

3. I f you checked "Yes" to Item D . l . , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:


4. The Disclosing Party further certifies that no prohibited financial interest in the Matter wi l l be acquired by any City official or employee.



Page 8 of 13



2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes ful l disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI -- C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S

NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section V I I . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.





Page 9 of 13

3. The Disclosing Party wil l submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above.


5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . I . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.




[ J Yes [ ] No



[ J Yes [ J No


[JYes [ JNo


[JYes [ J N o -


Page 10 of 13

SECTION VII ~ A C K N O W L E D G M E N T S , CONTRACT INCORPORATION, C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E


A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statates, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The ful l text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.




E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13


F.2 I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities wil l not use. nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

r.3 I f the Disclosing Party is the Applicant, the Disclosing Party wil l obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F . l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.



Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A ( i f applicable) are true, accurate and complete as of the date furnished to the City.

(Print 01* type name of person signing)

(Print or type title of person signing) f-er

Signed and sworn to before me on

at _ County, jL

(date) I/, TDI^S ( l i n O t i (state).

'-'f 'ClALSEAL

Sl^n'-^^"^-STATE OF ILLINOIS MY COMMISSION EXPIRES-12/14/16

\ Notary Public.

Commission expires:

Page 12 of 13


APPENDLX A




"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partaers of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[JYes [)(fNo

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is coimected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B




[ JYes [XlNo


[ J Yes [ J No [y] Not Applicable




AND AFFIDAVIT

S E C T I O N I ~ G E N E R A L INFORMATION



Indicate whether the Disclosing Party submitting this EDS is: 1. [ J the Applicant

OR 2. [J a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the


3. [P( a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control: t. A ( /r rt •f: c c ^ , L L C

B. Business address of the Disclosing Party:

C. Telephone: 1 1 3 - 73LS' - 0240Fax: EmaiL

D. Name of contact person:^\j<jo/^K L\jOo.(\\



G. Which City agency or department is requesting this EDS? K)^U



Ver. 01-01-12 Page 1 of 13

SECTION II -- DISCLOSURE OF OWNERSHIP I N T E R E S T S



[ J Person [ J Limited liability company [ J Publicly registered business corporation [J Limited liability partnership ..

Privately held business corporation [ J Joint venture [ J Sole proprietorship [ J Not-for-profit corporation [ J General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ J Limited partnership [ J Yes [ J No [J Trust [ J Other (please specify)



[ J Yes [ J No M N/A




Name Title


Page 2 of 13


Name Business Address Percentage Interest in the P, . Disclosing Party



[ J Yes ^ No


SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND O T H E R R E T A I N E D PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the reladonship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: ( I ) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.


Page 3 of 13


Relationship to Disclosing Party (subcontractor, attomey, lobbyist, etc.)



D<| Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.

SECTION V -- C E R T I F I C A T I O N S




[ J Yes p(f No [ J No person directly or indirectly owns 10% or more of the Disclosing Party.


[JYes [ JNo


1. Pursuant to Municipal Code Chapter 1-23, Arficle I ("Arficle I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Arficle I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities identified in Section I I . B . l . of this EDS:










other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Enfity (collectively "Agents").

Page 5 of 13






4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local govemment as a result of engaging in or being convicted of ( I ) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.




Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it wil l be conclusively presumed that the Disclosing Party certified to the above statements.


vone>




[ J is 1^ is not

a "financial institution" as defined in Secfion 2-32-455(b) of the Municipal Code.


"We are not and wil l not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them wil l become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."


Page 7 of 13





[JYes D^No

NOTE: I f you checked "Yes" to Item D . l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.



[ J Yes D<1 No



4. The Disclosing Party further certifies that no prohibited financial interest in the Matter wil l be acquired by any City official or employee.



Page 8 of 13


X I . The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.


SECTION VI - CERTIFICATIONS FOR F E D E R A L L Y FUNDED M A T T E R S

NOTE: I f the Matter is federally funded, complete this Secfion V I . I f the Matter is not federally funded, proceed to Section VI I . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligafions of the City are not federal funding.


1. List below the names of all persons or enfities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it wi l l be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or enfity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and wil l not engage in "Lobbying Activities".





[ J Yes [ J No


1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulafions? (See 41 CFR Part 60-2.)

[ J Yes [ J No


[JYes [ JNo


[ J Yes [ J No


Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION, C O M P L I A N C E , PENALTIES, D I S C L O S U R E


A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in cormection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.


C. I f the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement ( i f not rescinded or void), at law, or in equity, including terminafing the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Intemet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Intemet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the inforraafion provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Secfion 2-154-020 of the Municipal Code.


Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities wil l not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 I f the Disclosing Party is the Applicant, the Disclosing Party wi l l obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. 1. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F . I . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A ( i f applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A ( i f applicable) are true, accurate and complete as of the date furnished to the City.


^N'JclblnK LuCfCMM (Print of" type title of person signing)

Signechind sworn to before me on

i>t C J O O ^ County,

(date) P(\< \ ll^20l< [ \ . A O i S (stated

Notary Public.

OFFICIAL SEAL DAVID AUFRECHT

NOTARY PUBLIC - STATE OF ILUNOIS MY COMMISSION EXPIR£S:12/14/16


Page 12 of 13


APPENDDC A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partaer or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (I) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partaers and limited partaers of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[JYes [)<[No

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is coimected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B




[ JYes IXlNo

2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant idenfified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[JYes [ J N o [ y j Not Applicable



C I T Y OF C H I C A G O ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION I ~ G E N E R A L INFORMATION


l^nf)r KloU.^t^. LLC


Indicate whether the Disclosing Party submitting this EDS is: 1. [ J the Applicant

OR 2. ^ a. legal entity holding a direct or indirect interest in the Appficant. State the legal name of the

Applicant in which the Disclosing Party holds an interest: LA Cov^tA•ecClei(^ LL<L

OR 3. [J a legal entity with a right of control (see Section II .B. l . ) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 3 ? 2 ^ ^^0< \* ' ^Q 2 .

XL 60^1

C. Telephone: j^^l-31^-'^^-SQ Fax: Email:

D. Name of contact person:



G. Which City agency or department is requesfing this EDS?



Ver. 01-01-12 Page I of 13




Person Limited Uability company Publicly registered business corporation [J Limited liability partnership Privately held business corporation [ J Joint venture Sole proprietorship [ J Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ J Yes [ J No Tmst [ J Other (please specify)



[ J Yes [ J No N/A




Name Title

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint ventare.

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. I f none, state "None." NOTE: Pursuant to Secfion 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional informafion from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the . . . . Disclosing Party

S E C T I O N III ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ J Yes ^ No

If yes, please idenfify below the name(s) of such City elected official(s) and describe such relationship(s):

SECTION IV ~ DISCLOSURE OF SUBCONTRACTORS AND O T H E R R E T A I N E D PARTIES




Page 3 of 13










[ J Yes P^No [ J No person directly or indirectly owns 10% or more of the Disclosing Party.


[ J Yes [ JNo


I . Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities idenfified in Secfion I I .B . l . of this EDS:





e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions conceming environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.



connection with the Matter, including but not limited to all persons or legal enfities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local govemment, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or enfity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Enfity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13


a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a pubUc officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;







7. I f the Disclosing Party is unable to cerfify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it wi l l be conclusively presumed that the Disclosing Party certified to the above statements.

8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete fist of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none").

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general pubHc, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also Ust the name of the City recipient.



[ J is IJd is not




I f the Disclosing Party is unable to make this pledge because it or any of its affiHates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary):

Page 7 of 13


J). CERTIFICATION REGARDING INTEREST IN CITY BUSINESS



[ J Yes No


2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensafion for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.


[ J Yes 1X1 No

3. I f you checked "Yes" to Item D . I . , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:





Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor enfifies regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.


SECTION VI ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S

NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section V I I . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligafions of the City are not federal funding.




2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connecfion with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13







[ J Yes [ J No



[ J Yes [ J No


[ J Yes [ J No


[ J Yes [ J No


Page 10 of 13

S E C T I O N VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, C O M P L I A N C E , PENALTIES, D I S C L O S U R E


A. The certifications, disclosures, and acknowledgments contained in this EDS wil l become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statates, ordinances, and regulations on which this EDS is based.

B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The ful l text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .


C. I f the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement ( i f not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.


E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Secfion 2-154-020 of the Municipal Code.


Page 11 of 13



F.3 I f the Disclosing Party is the Applicant, the Disclosing Party wil l obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F . l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.


CERTIFICATION


(Print or type rrame of Disfclc IS, L ( .C

(Print or type rrame of Disfclosing Party)

By: 1f[J.(b P. / L L J M (Sign here)

^Wue AJ preys' (Print or type name of person signing)


Signed and sworn to before me on (date) at C o o t County, "X^tl/nOiX fstate).

t ^ ^ ^ ^ ^ y ^ ^ ^ Notary Public.

OFFICIAL SEAL DAVID AUFRECHT

NOTARY PUBUC - STATE OF ILUNOIS MY COMMISSION EXPINES:12n4/16


Page 12 of 13


APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partaers of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partaers and limited partaers of the Disclosing Party, i f the Disclosing Party is a limited partaership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal enfity or any person exercising similar authority.


[JYes [XfNo

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is coimected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise natare of such familial relationship.

Page 13 of 13


APPENDIX B




[ JYes [XlNo


[JYes [ ]No [Xl Not Applicable



City of Chicago



02015-4176

Meeting Date:

Sponsor(s):

Type:

Title:


5/20/2015


Ordinance

Zoning Reclassification Map No. 1-F at 640 N Wells St - App No. 18383 Committee on Zoning, Landmarks and Building Standards

/uiA^H^^i Zo)<, ORDINANCE

BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO

SECTION 1. That the Chicago Zoning Ordinance be amended by changing all of the DX-7 Downtown Mixed-Use District symbols and indications as shown on Map 1-F in the area bounded by:

West Erie Street; North Wells Street; West Ontario Street; a line 149.18 feet west of and parallel to North Wells Street; the public alley next north of and parallel to West Ontario Street; the public alley next west of and parallel to North Wells Street;

to those of a Residential-Business Planned Development.

SECTION 2. This Ordinance shall be in force and effect from and after its passage and publication.

Applicant: Wells & Erie LLC Address: 640 North Wells Street Introduced: May 20, 2015 Plan Commission: TBD

E ASIM 00622111 1

BUSINESS PLANNED DEVELOPMENT NO. PLANNED DEVELOPMENT STATEMENTS

1. The area delineated herein as Planned Development Number TBD ("Planned Development") consists of approximately 26,509 square feet of property which is depicted on the attached Planned Development Boundary and Property Line Map ("Property"). Wells & Erie LLC is the "Applicant" for this planned development pursuant to authorization of the owner of the Property.

2. The requirements, obligations and conditions contained within this Planned Development shall be binding upon the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to the requirements of Section 17-8-0400 of the Chicago Zoning Ordinance (the "Zoning Ordinance"), the Property, at the time of application for amendments, modifications or changes (administrative, legislative or otherwise) to this Planned Development, shall be under single ownership or designated control. Single designated control is defined in Section 17-8-0400 of the Zoning Ordinance.



Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Chicago Department of Planning and Development ("DPD") and CDOT. Closure of all or any public street or alley during demolition or construction shall be subject to the review and approval of CDOT.

All work proposed in the public way must be designed and constructed in accordance with CDOT Standards for Work in the Public Way and in compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by CDOT.

4. This Plan of Development consists of these 17 Statements; a Bulk Regulations and Data Table and the following exhibits and plans attached hereto prepared by Hartshome Plunkard Architecture and dated (the "Plans"): an Existing Zoning Map; an Existing LandUse Map; a Property and Planned Development Boundary Line Map; a Site Plan; a


EAS'n95597473.1

Green Roof Plan; a Landscape Plan; and Building Elevations (North, South, East and West). Full-sized copies of the Site Plan, Landscape Plan and Building Elevations are on file with DPD. In any instance where a provision of this Planned Development conflicts with the Chicago Building Code, the Building Code shall control. This Planned Development conforms to the intent and purpose of the Zoning Ordinance, and all requirements thereof, and satisfies the established criteria for approval as a Planned Development. In case of a conflict between the terms of this Planned Development Ordinance and the Zoning Ordinance, this Planned Development Ordinance shall control.

5. The following uses are permitted in the area delineated herein as a Business Planned Development: Dwelling units located above the ground floor; Animal Services; Artist Work or Sales Space; Eating and Drinking Establishments; Financial Services; Food and Beverage Retail Sales; Medical Service; Office; Personal Service; General Retail Sales; Valuable Objects Dealer; Parking; and related, incidental and accessory uses.



8. The maximum permitted Floor Area Ratio ("FAR") for the Property shall be in accordance with the attached Bulk Regulations and Data Table. For the purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted FAR identified in the Bulk Regulations and Data Table has been determined using a Net Site Area of 26,509 square feet and a base FAR of 7, and additional FAR for proposed FAR bonuses as follows:

Description FAR Base FAR: 7.00 Upper Level Setbacks: 0.21 Affordable Housing: 1.75 Transit Infrastructure: 1.40 Total FAR: 10.36

9. Upon review and determination, "Part II Review", pursuant to Section 17-13-0610 of the Zoning Ordinance, a Part II Review Fee shall be assessed by DPD. The fee, as determined by staff at the time, is final and binding on the Applicant and must be paid to the Department of Revenue prior to the issuance of any Part II approval.


CAS'n95597473.1

10. The Site and Landscape Plans shall be in substantial conformance with the Landscape Ordinance and any other corresponding regulations and guidelines. Final landscape plan review and approval will be by DPD. Any interim reviews associated with site plan review or Part II reviews, are conditional until final Part II approval.

11. The Applicant shall comply with Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation, Fleet and Facility Management and Buildings, under Section 13-32-125 of the Municipal Code, or any other applicable provision of that Code.

12. The terms and conditions of development under this Planned Development Ordinance may be modified administratively, pursuant to section 17-13-0611-A of the Zoning Ordinance, by the Zoning Administrator upon the application for such a modification by the Applicant, its successors, assigns and, if different than the Applicant, the legal title holders and any ground lessees of the Property.


14. The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resources. The Applicant shall seek LEED certification and provide a 50% net green roof equivalent to an actual total of 14,547 square feet.

15. Pursuant to the Affordable Housing Bonus provisions of Section 17-4-1004 of the Zoning Ordinance, the Applicant has requested an increase in the floor area of the Property. Prior to the issuance of any building permits authorizing the construction of any improvements in the Planned Development utilizing such bonus floor area, the Applicant shall make a cash payment to the City's Affordable Housing Opportunity Fund for the Affordable Housing floor area bonus in the amount of $ 1,595,816.

16. Pursuant to the Transit Infrastructure Improvements Bonus provisions of Section 17-4-1020 of the Zoning Ordinance, the Applicant has requested an increase in the floor area permitted on the Property based on a cash contribution for public transit infrastructure improvements. The Applicant shall make a cash contribution in the amount of $1,276,687, which corresponds to a floor area bonus of 1.40. Pursuant to Section 17-4-1020-A of the Zoning Ordinance, the Applicant must enter into an agreement with the agency undertaking the improvements providing for such cash contribution. The Commissioner may require


EAST\95597473.1

evidence that such cash contribution has been funded by the Applicant as a condition to issuance of any Part II approvals.

17. This Planned Development shall be governed by Section 17-13-0612 of the Zoning Ordinance. Should this Planned Development Ordinance lapse, the Commissioner of DPD shall initiate a Zoning Map Amendment to rezone the property to the DX-7 Downtown Mixed-Use District.


EAS'n95597473.1

RESIDENTIAL-BUSINESS PLANNED DEVELOPMENT NO. BULK REGULATIONS AND DATA TABLE

Gross Site Area (sf): 50,614 sf

Area of Public Rights-of-Way (sf): 24, 105 sf

Net Site Area (sf): 26,509 sf

Maximum Floor Area Ratio: 10.36

Maximum Number of Dwelling Units: 253

Minimum Off-Street Parking Spaces: 117

Minimum Off-Street Loading Berths: 1 (10'x25')

Maximum Building Height: 280'

Minimum Setbacks: In substantial conformance with the Plans

Applicant: Wells & Erie LLC Address: 200-212 W. Ontario; 628-648 N. Wells; 201 -209 W. Erie Introduced: May 20, 2015 Plan Commission: TBD

EAST\89515102.I

n ^ D L A I


Katherine C. Jahnke Dale [email protected] T 312.368.2153 F 312.251.2856

May 13, 2015

The Honorable Daniel Solis, Chairman City of Chicago Committee on Zoning Room 304, City Hall 121 North LaSaile Street Chicago, Illinois 60602


Re: Application for Residential-Business Planned Development Wells & Erie LLC

Dear Chairman Solis and Chairman Cabrera;

The undersigned, Katherine C. Jahnke Dale, an attorney with the law firm of DLA Piper LLP (US), which firm represents Wells & Erie LLC, the applicant for an amendment to the Chicago Zoning Ordinance and proposed planned development, certifies that she has complied with the requirements for Section 17-13-0107 of the Chicago Zoning Ordinance by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet of each direction of the lot line of the subject property, exclusive of public roads, streets, alleys and other public ways. Said written notice was sent by First Class U.S. Mail, no more than 30 days before filing the application.



Very truly yours,

DLA Piper LLP (US)

Subscribed and swocn to before me / r '^davof This

Not iry Public

. 2015.


• ILUANA RAMOS I % Notary Public, State of Illinois *

EAST\100482004.1

DLA PIPER DLA Piper LLP (us) 203 North LaSalle Street, Suite 1900 Chicago, Illinois 60601-1293 www.dlapiper.com

Paul Shadle [email protected] T 312.368.3493 F 312.251.5670

May 13, 2015

FIRST CLASS MAIL

Dear Sir or Madam:

As required by Section 17-13-0107 of the Municipal Code of the City of Chicago, please be Informed that on or about May 13, 2015, the undersigned, on behalf of Wells & Erie LLC (the "Applicant"), intends to file an application to rezone the property located at 200-212 West Ontario; 628-648 North Wells Street; 201-209 West Erie Street, Chicago, IL 60654 from the DX-7 Downtown Mixed-Use District to a Residential-Business Planned Development. A map of the development site is printed on the reverse side of this letter.

The development site is currently utilized as a restaurant with a surface parking lot. The Applicant seeks approval of plans to allow for construction of a 22-story residential building and 2-story commercial building containing up to 253 dwelling units, accessory parking, commercial uses, and accessory and incidental uses.

The proposed change of zoning does not apply to your property. You are receiving this notice as required by the Chicago Municipal Code because the Cook County Assessor's records indicate that you own property within 250 feet of the development site.

I am an authorized representative of the Applicant and my address is 203 North LaSalle Street, Suite 1900, Chicago, IL 60601. The Applicant's address is 908 North Halsted Street, Chicago, Illinois 60642. The owner of the development site is Erie Wells, LLC, whose address is 600 West Jackson, Suite 200, Chicago, Illinois 60661.


Very truly yours.

X-P^per LLP (US)

Paul Shadle

EASTM 00481393.2

AUTHORIZATION

The undersigned, ERIE WELLS, LLC, an Illinois limited liability company, being the owner of real property located generally at 200-212 West Ontario; 628-648 North Wells Street; and 201-209 West Erie Street in Chicago, Illinois (the "Subject Property"), hereby authorizes WELLS & ERIE LLC, an Illinois limited liability company, and any affiliate or designee thereof and its attorneys, DLA Piper LLP (US), to file one or more applications for zoning approvals and related permits and approvals with the City of Chicago relating to the Subject Property.

IN WITNESS WHEREOF, the undersigned has executed this Authorization as of this 8' day of January, 2014.

ERIE WELLS LLC

by Debevics LLC, manager /i

Dinev/jLTD, minager of Debevics LLC

EAST\89514584.I


640 N- WELLS PROPOSED 22 STOnY BUIIDING

210 W. WELLS PROPOSCQ 2 STORY BUIIOWG

PINs:

17-08-223-006 to -013

EAST\100481393.2

NG

WE

LL

S

ST

OR

Y B

UIL

DI

CM CM

CD

CO

PR

OP

OS

ED

2

a CO

m >-

LXJ GC

Tn

1 u

CO

D2

O or

SE

I " o CNJ U

r

QC a .

CD

O

CD

CO X

o CO

II

u CO

CO

CO

CO ^ _ i up — CO o "

^ cc O LU

CM 03 T— O CM CM cb o o CM CM

o GC Q-L l _ O CO oo LU cc a o < I

CO

o

Q_

<E O

o I —

C I o GC

>-UJ i t :

a a 0 0 CO L U L U CC QC QC

ZJ Zj ca

^ S ^ g P iiJ i= = 1 r r , I ^ L U < : Z =3 1= ^ " — 5 00 [ T 0 0 • = L U U_ "-LJ

II II c c o S — CM n n n

< X C J L U U -

C 3

a

• CO

1 CO

LU >-cc

ST

O

CM CM

CD a L U CO

CO

PR

OP

O

CM <

m i .

i S l i

AUVQNnOS AiUBdOUd ,00^

C/E

6-S

TO

RY

1-S

TO

RY

(41

-ST

OR

Y A

2

TO

WE

R

PLA

NN

ED

I . >- 1— cn

/A2

ST

OR

CO

<

t 3

ELLS

RY

BU

IL

Tfl

1

u

0 0 CM

C 3 L U OO

o CNJ

PR

OP

CO

CO « * _ i CO — CO o " CNJ en CO ^

oo

o oo oo

o

cc C-3i

O L U

CNI C35 >— CD CM CM cb O O CNI CM

O CC Q -

< t 0 0 C-3 L U

CC

o h -C J

o cc

< o

< ^ Q > -2 1— •=> oc

°^ O Q OC

C O

U -L l _ C/3

co CO C D

L D O L O O \n II U 3 II

CM

< CM II

ITE

A

RI

RO

W

=

AR

EA

SS

L U 1—

CO < C O

O L U 1—

cc CC L U C3 <

J L W. ERIE ST.

A3n\/3nand-\i

.ilNIARiCLSL ONE-WAY TRAFFIC

O

Q-O QC Q_

OL.

>-CC

o ID O 03

cp C3

Ln

CJ 00

oo

oo _ l

CO — oo o Csl r n CO <£

o t3

o oo oo

o

I Q-

cc •a: CO

O UJ

CSI C35 «— O CM CM

CNI CM

CJ

CD CC Q-LL. O

OO CO LU CC a a

u C3 O CC

25.02' n.

1

/ / - , c /•. •• •••/ ••• c: ••:/•• A ° . y/^

y / ^

/ / - , c /•. •• •••/ ••• c: ••:/•• A ° . y/^

y / ^ •1 / / - , c /•. •• •••/ ••• c: ••:/•• A ° . y/^

y / ^

/ / - , c /•. •• •••/ ••• c: ••:/•• A ° . y/^

y / ^

i / ^ j t A i 1 / Ti i iK t

W. ONTARIO ST ' ONE-WAY TRAFFIC

U i O Z UJ

Q

8 ^

LU - r

'O

5i/ O UJ

Q

O

- ' U -

5 Q

0

/

oo

J ^

y,

25.02' P.L

W. ERIE ST

25:02 P.L

„6-,El „o-.ou

W. ONTARIO ST ONE-WAY TRAFFIC

CO

o cc

CO _ i

CO —

ob o CNJ t r j

o

C J

a LU

CM CJ3 T— o CM CM

cb ^ CD CD CM CNJ

C J

o cc Q -

00 oo L U cc a

CM CO

•a: C J CO

oo CO

o C J

C J

a o cc

. o o ^ Q »- £ v» Q m LU ^

c CO =

I s l f o i i w S

. o o u3 t Q >; £ CO a S " m o § g ^ )_ g E E i ^ S •« c -CO o t

c ca S u> " ° 3 = X D z a u

i S s « o ° [L tt a >- ? w D S 5: S

8 w> « o o a ^ g £

5 e= " £ . . J — UJ o ; UJ ^ o a I— h

o S UJ c o =3 = ;

CO >-•a z

L U o z

QC o L U

•a CJ CO Q

e 3 E *< 9 " s s ; ' : ^ ~ O O O f

S - P= = = t

P ^ C3 g

t o p P

m = O O O (. ^ _ c c OC BC L

i i i i i ^ !2 z = i 1 s

CJ CO

C J

CNJ C O

•a: C J 0 0

oo

oo _ l

C O —

ob o CNI {TJ C O

o cc

z cc O L U

CM (33 <— C J CM C M

cb "- CD CD CNJ CNJ

C J L U —3 o cc a . U -

o CO 0 0

C O 0 0

o C J

< 3 :

a

o I— C J

=) C D O C C

a

\/y/

II

< II L U II CC

< I I I

RE

I

AB

U

:QU

I

o OC II

AP

PL

^O

OF

CA

PE

U - CO o o o U J z cc OC < z L U L U

iL

u

< L U CC U - <: L l _ OC L t -

13 co 1— Q

CO < co 1 1 r~. 1

< CTJ •<d- < 1— O 1— L D

O CD o o 1— CNI 1—

W. ERIE ST.

/ / /

y /

y^^y •••• 1 y / / / .' / , / / . t i l

• •/' / /

ol o6|

// •. •• / y -' ^ CM

A3mvonand ^ 25.02'P.L. o

CO

J_!_L_LL_L44-1.0.-1£1£.U I I I I I

W. ONTARIO ST. <=

ONE-WAY TRAFFIC

V o UJ Q

0 O O - J

Q In CM

z _a CM -Ii U l 1— Ul

•••/•

CD

CO

oo _ i

CO — ob o CM CD CO : ^

CC CJ

S OC

LO II

CJ CO

o CO

oo

o CJ

CM CD T— CJ CM CM

CJ o CM CM

CJ

O CC Q-

co oo

a

C3 o cc

4

T/ELB«THROOI>CL4e ELi «»-•«•'

T/TBTHaOCRlUB EL 44'-* '

T;N*CTHHjOaiaL>IB

j;EianrnnjanLJB

4 kT/ai»fTnaocwai>e p E u v - i r

V E b

,T; ttCOP H.QOW eL4B

- \ -

- \ -

ii I I I I I I r I 1 I r r I I

—12'-3", V >

— ll'-3" -7-^ X

1 1 1 1 I I T I 1 I r i

j z n i - L

at,

' 111111' IFB— 02

L I I . I

01

08

IE 09

ONTARIO ST. ERIE ST

MATERIAL LEGEND: ^ PRECAST COLUJIN COVER [ail ALiniNui IUINDDUJ [B]METAL PANEL IUALL [¥]RECESSED LiciHTiNa [M]PAINTED STEEL

[gi] PORCELAIN STOe CLADDING |g5| PAINTED CONCRETE ALUMINUM CURTAIN lUALL [¥] NOT USED [IT] EXPANSION JOINT

METAL/tSLASS RAILIMi | ^ GLASS PARAPET j j i ] ALUMINUM STOREFRONT [w] NOT USED [¥] OVERHEAD GARAGE DOOR

BOARD FORMED CONCRETE |OT] SLAB EDGE COVER [T| LOJ-E INSULATED VISION GLASS [§] REVEAL 3RIOC

APPLICANT: PLAN COMMISSION: TBD WELLS & ERIE LLC SCALE: 1"=40"-0"

EAST ELEVATION ADDRESS OF PROJECT: EAST ELEVATION 200-212 W ONTARIO; 628-648 N WELLS; 201-209 W ERIE CHICAGO, IL EAST ELEVATION INTRODUCTION DATE:

EAST ELEVATION

kT/ TCP Of ELftt mOHM

WELLS ST. ALLEY

MATERIAL LEGEND: 0 PRECAST COLUMN COVER ALUMINUM UIINDOU [JUMETAL PANEL IUALL [jfe]RECESSED LIGHTING [^PAINTED STEEL

[eji PORCELAIN STONE CLADDING ^ PAINTED CONCRETE ^ ALUMINUM CURTAIN lUALL |J3]NOT USED [n] EXPANSION JOINT

METAL/CLASS RAILING GLASS PARAPET [ja] ALUMINUM STOREFRONT [ M ] NOT USED rig] OVERHEAD GARAGE DOOR

[03| BOARD FORMED CONCRETE |OT] SLAB EDGE COVER (T| LOIU-E INSULATED VISION GLASS [¥] REVEAL [B]BRICK

APPLICANT: PLAN COMMISSION: TBD WELLS & ERIE LLC SCALE: 1"=40"-0"

NORTH ELEVATION ADDRESS OF PROJECT: NORTH ELEVATION 200-212 W ONTARIO; 628-648 N WELLS; 201-209 W ERIE CHICAGO, IL NORTH ELEVATION INTRODUCTION DATE:

NORTH ELEVATION

/4,T/T0PCFW0e '^ELi ' t fB-r

'EL 04'-r

T/>»CTOrHFUO0»flUB 'EL. 45--4-

'ELI

'EL trn-v

'EL «•'-*• ELi « ' - W

T/«WTHnJCTieL«B EL « ' - « •

EL v - i r

T/WWFLOCW«

• ^^EL t+4'-«'

1-

•-\— 1-

® r

T/nioTftoemt>B

9

-i-

22

5'-5"

W-1 1/2"

• 06

02

01

08

II

ir-4"

5'-5"

01

04

10

ALLEY WELLS ST.

MATERIAL LEGEND: |04| PRECAST COLUMN COVER ^ ALUMINUM UINDDU) [J2]METAL PANEL IUALL [i]RECESSED LIGHTING [M]PAINTED STEEL

[01] PORCELAIN STONE CLADDING PAINTED CONCRETE ALUMINUM CURTAIN IUALL [iijNOT USED [n] EXPANSION JOINT

[i2| METALA3LASS RAILING | ^ GLASS PARAPET ALUMINUM STOREFRONT [k] NOT USED fis] OVERHEAD GARAGE DOOR

BOARD FORMED CONCRETE |0T] SLAB EDGE COVER [ j i ] LOU-E INSULATED VISION GLASS [¥] REVEAL [BJBRIOC

APPLICANT: PLAN COMMISSION: TBD WELLS & ERIE LLC SCALE: 1" = 40'-0"

SOUTH ELEVATION ADDRESS OF PROJECT: SOUTH ELEVATION 200-212 W ONTARIO; 628-648 N WELLS; 201-209 W ERIE CHICAGO, IL

SOUTH ELEVATION INTRODUCTION DATE:

SOUTH ELEVATION

^ E L or - i

BOO

KwnEBfftlHjOOWtUIB

• "^EL *1'-4'

^ E L

^ E L 0» ' - * '

'-'EL «•-•• E L «B - r

A.T;EIQHmR

' ^ E L i

^ E L *44'-r

1 CM

I T

HE

•

I I I I T T T l

O

n

' 0b

XX 02

01

08

m ,

i ir-i01/2"

• Z L I0'-10 1/2"

7^ ' X

04

ERIE ST. ONTARIO ST

MATERIAL LEGEND: @ PRECAST COLUMN COVER ALUMINUM IUNDOIU [C]METAL PANEL UIALL [¥]RECESSED LIGHTING [20I PAINTED STEEL

@ PORCELAIN STONE CLADDING | ^ PAINTED CONCRETE ALUMINUM CURTAIN IUALL [E] NOT USED [IT] EXPANSION JOINT

[OT| METAL/GLASS RAILING ^ GLASS PARAPET [10] ALUMINUM STOREFRONT [ M ] NOT USED |¥] OVERHEAD GARAGE DOOR

BOARD FOfgiED CONCRETE ^ SLAB EDGE COVER [¥] LOU-E INSULATED VISION GLASS REVEAL [I i ] BRICK

APPLICANT: PLAN COMMISSION: TBD WELLS & ERIE LLC SCALE: 1"=40'-0"

WEST ELEVATION ADDRESS OF PROJECT: WEST ELEVATION 200-212 W ONTARIO; 628-648 N WELLS; 201-209 W ERIE CHICAGO, IL WEST ELEVATION INTRODUCTION DATE:

WEST ELEVATION

ROOF : *2fc'-fe"

T/ SECOND FLOOR SLAB EL: +15'-4"

1/ FIRST FLOOR SLAB

M ROOF

EL: +0'-0"

NORTH ELEVATION

^ 1/ rsc EL: +26'-fc"

1/ SECOND FLOOR SLAB ^EL: +15'-4"

J / FIRST FLOOR SLAB 'EL: *(2)'-0"

^ T / ROOF

4

EAST & WEST ELEVATIONS

EL: +2fe'-6"

1/ SECOND FLOOR SLAB

—

EL: +l5'-4"

1/ FIRST FLOOR SLAB

I

In I

In

EL:

^ .SOUTH ELEVATION

20

19

10

MATERIAL LEGEND: |M] PRECAST COLUMN COVER ^ ALUMINUM IUINDOIU [C]METAL PANEL IUALL ]J6]RECESSED LIGHTING [ZC]PAINTED STEEL

1 ^ PORCELAIN STONE CLADDING jgs] PAINTED CONCRETE [gj] ALUMINUM CURTAIN IUALL ]j i ] NOT USED ITT] EXPANSION JOINT

[02] METAL/GLASS RAILING ^ GLASS PARAPET [10] ALUMINUM STOREFRONT ]j4] NOT USED ] j i ] OVERHEAD GARAGE DOOR

BOARD FORMED CONCRETE |OT] SLAB EDGE COVER [Tj LOIU-E INSULATED VISION GLASS [¥] REVEAL ]j | ] BRICK

APPLICANT: PLAN COMMISSION: TBD WELLS & ERIE LLC SCALE: 1/16"= I'-O"

SUBAREA B ELEVATIONS

ADDRESS OF PROJECT: SUBAREA B ELEVATIONS 200-212 W ONTARIO; 628-648 N WELLS; 201-209 W ERIE CHICAGO, IL


INTRODUCTION DATE:


M M S U R V E Y I N G CO. , INC. PKOFBSSIONAL DESION FIRM No 184-4)03233

A L T A / A C S M Land Title Survey

- t k-;- - - W^T -HE « r f E - — S T 7 +_

L

GRAPHIC SCALE

r

IAWJA»TI1.10H

WCLU AEKM UC. 1

VICPJITY MAP

o convT (WI m OK n x r M O M C M K C V CH B MED a l M I N C M HKOWaCt MIX Ttf. U l l

f i H t t M C DTtM. ( r a k M i a K n r t » j c i v c s w c m i ^ JMOLt a u K « s J M ) t a a r r t i n 4 A M P I > M ] B T I l « l J J . ' . ' ' t , ' » . 1 . > » , M m c t » - •

^ ' 8 3 8 3

CITY OF CHICAGO , ^



200-212 West Ontario: 628-648 North Wells Street: 201-209 West Erie Street

2. Ward Number that property is located in: 42nd Ward

3. APPLICANT Wells & Erie LLC

ADDRESS 908 North Halsted Street


PHONE 312-642-0850 CONTACT PERSON Robert D. Stone

Is the applicant the owner of the property? YES NO X If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the applicant to proceed.

OWNER Erie Wells. LLC

ADDRESS 600 West Jackson. Suite 200


PHONE 312-463-1210 CONTACT PERSON Jeffrey Himmel


ATTORNEY Paul Shadle & Katie Jahnke Dale - DLA Piper LLP fUS)

ADDRESS 203 N. LaSalle Street. Suite 1900


PHONE (312) 368-3493 /-2153 FAX (312)251-2856

EMAIL paul.shadle(a)diapiper.com / katie.dale(a)dlapiper.com

BAS1'\97S14813 1

6. If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements:

See attached Economic Disclosure Statements

On what date did the owner acquire legal title to the subject property? Februaiy 2005

Has the present owner previously rezoned this property? If yes, when? No

Present Zoning District DX-7 Downtown Mixed-Use District

Proposed Zoning District Residential-Business Planned Development

10. Lot size in square feet (or dimensions) +1- 26,509 square feet

11. Current Use of the Property Restaurant, Surface Parking

12. Reason for rezoning the property To allow for construction of a +/- 280' residential building and +/-

26'6" commercial building containing an overall FAR of 10.36, up to 253 dwelling units, accessoi'v

parking, commercial uses, and accessory and incidental uses.


The Applicant requests a rezoning of the subject property from the DX-7 Downtown Mixed-Use District and to Residential-Business Planned Development to allow for construction of a +/- 280' residential building and +1- 26'6" commercial building containing an overall FAR of 10.36. up to 253 dwelling units, approximately 117 parking spaces, commercial uses, and accessory and incidental uses.

14. On May 14"', 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See fact Sheet for more information)

YES X NO

EAS'n97514813.1


James D. Lctchinger, authorized signatory of WELLS & ERIE LLC, being first duly sworn on oath, state.s that all of the above statement.s and the statements contained in the documents submitted herewith are true and con-cct.

Sub.scribed and Swom to before me this ^ day of R j ) o l ^ . 2015.

Notary^ Public

Signat^ire of Applicant

• "OFFICIAL SEAL" % X ILLIANA RAMOS • • Notary Public, State of Illinois • i My Commission Expires 01 /10/2016 *

For Office Use Only

Date of Introduction:,

File Number:

Ward:

EASTO7514813.1

C I T Y OF C H I C A G O E C O N O M I C D I S C L O S U R E S T A T E M E N T


S E C T I O N 1 - G E N E R A L INFORMATION


WeWs & Erie LLC


Indicate whether the Disclosing Party submitting this EDS is:

1. [x] the Applicant OR

2. [ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest:

OR 3. [ ] a legal entity with a right of control (see Section ILB.L) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 908 North Halsted street

Chicago, IL 60642

C. Telephone: 312-642-0850 Fax: 312-642-9696 Email: rdstone(5)idlcorp.com

D. Name of contact person: Robert D. Stone .

E. Federal Employer Identification No. ( i f you have one): _


Zoning Amendment for property located at 200-212 West Ontario; 628-648 North Wells Street; and 201-209 West Erie Street



Specification # N/A and Contract # N/A

Ver. 01-01-12 Page 1 of 13

S E C T I O N II -- D I S C L O S U R E O F OWNERSHIP I N T E R E S T S


1. indicate the nature of the Disclosing Party:

Person ^ ] Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)


l inois

3. For legal entities not organized in the Slate of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [ ] No [x] N/A




Name Title

James D. Letchinger Manager


Page 2 of 13


Name

Erie Wells, LLC

Business Address

600 W. Jackson#200

Percentage Interest in the Disclosing Party

10% Chicago, IL 60661

SJAJ Wells, LLC 908 North Halsted Street 90% Chicago, IL 60642

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S


[ ] Yes [x] No


S E C T I O N IV - - D I S C L O S U R E OF S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S




Page 3 of 13



Suite 1900 " > — , — I . - » I

Chicago, IL 60601

Hartshome Plunkard, Ltd 232 North Carpenter Street Architect $10,000 e ^ .

Chicago, IL 60607



S E C T I O N V ~ C E R T I F I C A T I O N S






[ ] Yes [ ] No



Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B. 1. of this EDS:











Page 5 of 13










N/A

Page 6 of 13


8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago ( if none, indicate with "N/A" or "none").

None

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a " g i f f does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient ( i f none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

None



[ ] is ^ ] is not





Page 7 of 13





[ ] Yes [X] No

NOTE: I f you checked "Yes" to Item D . l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed lo Part E.



[ ] Yes [ ] No






Page 8 of 13



2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes fu l l disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

S E C T I O N VI ~ C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S




( I f no explanation appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it wi l l be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and wi l l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13



5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such .subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.




[ ] Yes [ ] No


1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal reguladons? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No


[ ] Y e s [ ] N o


[ ] Y e s [ ] N o


Page 10 of 13

S E C T I O N VII - A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N , C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E


A. The cerdfications, disclosures, and acknowledgments contained in this EDS wil l become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City acdon, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The ful l text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .




E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the dme the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Secdon 2-154-020 of the Municipal Code.


Page 11 of 13

F.l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entides delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its AffiHated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l . and F.2. above and will not. without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION


Wells & Erie LLC

(Print ortype name of Disclosing Party)

(Sign here)

James D. Letchinger


Manager (Print or type title of person signing)

Signed and sworn to before me on (date) f^'X | | ^ ^ J OIS at—frrjq-L —e-OTintyr—Sfirf^j^n (state)-

Commission expires: i/lO//h'

Notary Public.

Page 12 of 13

« -OFFICIAL SEAL" S I ILLIANA RAMOS % % Notary Public, State of Illinois * t MV Commission Expires 01 /10/2016 «


APPENDIX A


This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant

Under Municipal Code Secdon 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial reladonship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Apphcable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a Hmited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes [X ] No

If yes, please identify below (1) the name and dtle of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial reladonship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B




[ ]Yes [X]No

2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Secdon 2-92-416 of the Municipal Code?

[ ] Yes [X]No [ ] Not Applicable


F I L L I N G OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.




A. Legal name of the Disclosing Party submitdng this EDS. Include d/b/a/ i f applicable:

Erie Wells, LLC


Indicate whether the Disclosing Party submitting this EDS is: 1. p] the Owner

OR 2. [X] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest: Wells & Erie LLC OR

3. [ ] a legal entity with a right of control (see Section I I .B. l . ) State the legal name of the endty in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 600 w. Jackson #200

Chicago, IL 60661

C. Telephone: 312-463-1210 Fax: 312-798-6761 Email: JhimmelcgBravorestaurants.com

D. Name of contact person: Jeffrey Himmel

E. Federal Employer Identification No. ( i f you have one):

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and locadon of property, i f applicable):




Specification # N/^ and Contract # N/A

Ver. 01-01-12 Page 1 of 13

S E C T I O N II ~ D I S C L O S U R E OF OWNERSHIP I N T E R E S T S


I . Indicate the nature of the Disclosing Party:

Person ^ Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)


I l l i n o i s

3. For legal entides not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [ ] No 1^ N/A



I f the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal endty listed below must submit an EDS on its own behalf

Name Title Debevic's^ LLC Manager

2. Please provide the following informadon concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.

Page 2 of 13



Marshall Dickler 85 W. Algonquin Rd. #420, Arlington Heights, IL 60005 33.3334%

Larry Kanar 471 White Oak Lane, Riverwoods, IL 60015 33.3333%

Debevics LLC 600 W. Jackson #200, Chicago, IL 60661 33.3333%

S E C T I O N III - BUSINESS R E L A T I O N S H I P S WITH C I T Y E L E C T E D O F F I C I A L S


[ ] Yes [X] No

I f yes, please identify below the name(s) of such City elected official(s) and describe such reladonship(s):

S E C T I O N IV ~ D I S C L O S U R E OF S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S


"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or endty other than: (1) a not-for-profit endty, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.


Page 3 of 13


Relationship to Disclosing Party Fees (indicate whether (subcontractor, attorney, paid or estimated.) N O T E : lobbyist, etc.) "hourly rate" or "t.b.d." is




S E C T I O N V - C E R T I F I C A T I O N S


Under Municipal Code Section 2-92-415, substantial owners of business entides that contract with the City must remain in compliance with their child support obligations throughout the contract's term.


[ ] Yes No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Ardcle I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal endty, all of those persons or endties identified in Section I I . B . l . of this EDS:


b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transacdon; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;






connecdon with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or endty that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;


Page 5 of 13



b. agreed or colluded with other bidders or prospecdve bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of compeddon by agreement to bid a fixed price or otherwise; or




5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Endty List and the Debarred List.



Page 6 of 13



N / A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execudon date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient ( i f none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

N / A



[ ] is 1^ ^'^^




I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-45 5(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach addidonal pages i f necessary):

Page 7 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it wi l l be conclusively presumed that the Disclosing Party cerdfied to the above statements.




[]Yes XI No

NOTE: I f you checked "Yes" to Item D. L , proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.



[ ] Y e s [ ] N o






Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor endties regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.


S E C T I O N VI - C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S

NOTE: I f the Matter is federally funded, complete this Secdon V I . I f the Matter is not federally funded, proceed to Section V I I . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.


1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1 995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets i f necessary):

(I f no explanation appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it wi l l be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)


Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organizadon described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and wi l l not engage in "Lobbying Activities".

5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duradon of the Matter and must make such cerdfications promptly available to the City upon request.


I f the Matter is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in wridng at the outset of negotiations.


[ ] Y e s [ ] N o


1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal reguladons? (Sec 41 CFR Part 60-2.)

[ ] Y e s [ ] N o


[ ] Y c s [ ] N o


[ ] Y c s [ ] N o

I f you checked "No" to quesdon 1. or 2. above, please provide an explanadon:

Page 10 of 13

S E C T I O N V I I - A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N , C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E


A. The certificadons, disclosures, and acknowledgments contained in this EDS wi l l become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City acdon, and are material inducements to the City's execution of any contract or taking other acdon with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The ful l text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.


C. I f the City determines that any informadon provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement ( i f not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.




Page 11 of 13

F . l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,-sewer charges, license fees, parking dckets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities wi l l not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party wi l l obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F . l . and F.2. above and wil l not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F . l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.


Under penalty of perjury, the person signing below: ( I ) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A ( i f applicable) are true, accurate and complete as of the date furnished to the City. Erie Wells, LLC ^ by Debevics LLC, mgi; ; DebevicyDlneriLTD. mgr of Debevics LLC / .

(Prin/or type.name of pi"sclosiri'g''Party)

By:

/Sign ' f tbre/ / / /

Jeffrey Himmel (Print or type name of person signing)

Vice President


Signed and sworn to before me on (date) 6 0 0 ^ County, |.UAtJ:0|\% (state).

Notary Public.


Page 12 of 13

ilk » n m m 1 ii, ti, A a it OFFICIAL SEAL

LAUREN PRATSCHER NOTARY PUBLIC - STATE OF ILUNOIS

MY COMMISSION EXPIRES JULY 17,2018

C I T Y OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "famihal reladonship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adopdon: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all execudve officers of the Disclosing Party listed in Secdon II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes ^ No

If yes, please identify below (1) the name and dtle of such person, (2) the name of the legal entity to which such person is connected; (3) the name and dde of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B




[ ]Yes [X]No









SJAJ Wells LLC




Applicant in which the Disclosing Party holds an interest: wells & Erie LLC OR

3. [ ] a legal entity with a right of control (see Section I I .B. l . ) State the legal name of the endty in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 908 North Halsted Street

Chicago, IL 60642

C. Telephone: 312-642-0850 Fax: 312-642-9696 Email: rdstone(Sidlcorp.com

D. Name of contact person: Robert D. Stone

E. Federal Employer Identificadon No. ( i f you have one): _






Ver. 01-01-12 Page 1 of 13




Person | ^ Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit coiporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)


Illinois

3. For legal enddes not organized in the State of Illinois: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [ ] No [ ] N/A




Name Title James D. Letchinger Manager


Page 2 of 13



Letchinger Family LLC 908 N. Halsted Street, Chicago, IL 60642 100%

SECTION III - BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D OFFICIALS

Has the Disclosing Party had a "business reladonship," as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes ^ No


SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or esdmated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.



Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated to be retained)

DLA Piper

Address (subcontractor, attorney, lobbyist, etc.)

203 North LaSalle Attorney

paid or estimated.) NOTE: "hourly rate" or "t.b.d." is not an acceptable response.

$10,000.00 f><:V,

Chicago, IL 60601

Hartshome Plunkard, Ltd 232 North Carpenter St. Architect $10,000.00 es

Chicago, IL 60607



SECTION V -- CERTIFICATIONS


Under Municipal Code Section 2-92-415, substanfial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the contract's term.


[ ] Yes No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o


I . Pursuant to Municipal Code Chapter 1-23, Ardcle I ("Article r')(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13






e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violadons, instituted by the City or by the federal government, any state, or any other unit of local government.






Page 5 of 13






4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violadon of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.



7. I f the Disclosing Parly is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it wil l be conclusively presumed that the Disclosing Party cerdfied to the above statements.


None


None



[ ] is ^ is not



"We are not and wil l not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."


Page 7 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it wil l be conclusively presumed that the Disclosing Party cerdfied to the above statements.




[ ]Yes ^ N o

NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.



[ ] Yes [ ] No

3. I f you checked "Yes" to Item D.L, provide the names and business addresses of the City officials or employees having such interest and idendfy the nature of such interest:





Page 8 of 13


1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducdng the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:


NOTE: I f the Matter is federally funded, complete this Section VI . I f the Matter is not federally funded, proceed to Section VI I . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.





Page 9 of 13

3. The Disclosing Party will submit an updated certificadon at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above.

4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in secdon 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Acdvides".





[ ] Yes [ ] No


1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal reguladons? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No


[ ] Yes [ ] No


[ ] Yes [ ] No


Page 10 of 13



A. The certifications, disclosures, and acloiowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.


Sedgwick St, Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

C. I f the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosmg Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the informadon provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any informadon submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Ardcle I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13

F. l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entides delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parlies List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.


CERTIFICATION


SJAJ Wells LLC


By^

James D. Letchinger


Manager


Signed and sworn to before me^_on (date) ('jjXl i , QO IS" -at (JuCrt. C-Q-u-iTty, LHnlO'r^—(^'(^XQ)-

^^jAJAIAyy]^ ^ ^ ^ ^ J ^ Notary Public. V** ' 'A^^?\olVslf i l" ' ' ^ ' " \ / I ILLIANA RAMOS *

Commission expires: I / l O / l . % Notary Public, State of Illinois * f T— jMyCommissionExpiresO1/10/2016e

Page 12 of 13


APPENDIX A




"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief fmancial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes PC No


Page 13 of 13

C U V OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX B



1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofllaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ I Yes [x ]No

2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofllaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?


If yes to (I) or (2) above, plea.se identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.


C I T Y O F C H I C A G O E C O N O M I C D I S C L O S U R E S T A T E M E N T




Debevic's .LLC



OR 2. ^ a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest: ERIE WELLS. LLC OR

3. [ ] a legal entity with a right of control (see Section I I .B. l . ) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 600 W. Jackson #200

Chicago, I L 60661

C. Telephone: 312-463-1210 Fax: 312-798-6761 Email: [email protected]

D. Name of contact person: J e f f r e y Himmel

E. Federal Employer Identification No. ( i f you have one): _





Specification # N/A and Contract #

Ver. 01-01-12 Page 1 of 13

SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS


1. Indicate the nature of the Disclosing Party: [ ] Person j ^ ] Limited liability company [ ] Publicly registered business corporation [ ] Limited liability partnership

i ' Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501 (c)(3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

I l l i n o i s


[ ] Yes [ ] No 1 ] N/A


1. List below the full names and tities of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title Debevics Diner LTD Manager


Page 2 of 13


Name

Marshall Dickler

Business Address Percentage Interest in the

Disclosing Party 85 W. Algonquin Rd. #420, Arlington Heights, IL 60005 12.510%

Larry Kanar 471 White Oak Lane, Riverwoods, IL 60015 12.510%

Debevics Diner Ltd 600 W. Jackson #200, Chicago, IL 60661 8.940%

John Fyfe 630 W. Fullerton, Chicago, IL 60614 25.020%

Fyfe Childrens Partnership 630 W. Fullerton, Chicago, IL 60614 10.000% DK Eds LLC 600 W. Jackson #200, Chicago, IL 60661 16.680%



[ ] Yes [X] No


S E C T I O N IV - D I S C L O S U R E OF S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S




Page 3 of 13





1 Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.





[ ] Yes ^ No [ ] No person directly or indirectly owns 10"/o or more of the Disclosing Party.


[ ] Yes [ ] N o


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities

identified in Section I I . B . l . of this EDS:











Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affihated Entity, or an Affihated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:





4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of ( I ) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.




Page 6 of 13


8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago ( i f none, indicate with "N/A" or "none").

N / A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a " g i f f does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient ( i f none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

N / A



[ ] is ^ is not



"We are not and wi l l not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them wil l become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."


Page 7 of 13





[ ] Y e s ^ N o




[ ] Yes ^ No






Page 8 of 13


^ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.


S E C T I O N V I ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S




N / A



Page 9 of 13







[ ] Yes [ ] No



[ ] Yes [ ] No


[ ] Yes [ ] No


[ ] Y e s [ ] N o


Page 10 of 13

S E C T I O N V I I ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N , C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E


A. The certifications, disclosures, and acknowledgments contained in this EDS wi l l become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.


Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the apphcable ordinances.





Page 11 of 13

F.l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (I) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

Debevics LLC

Debevics Diner LTD mgr

(Print or, type name of Disclosing Party)

By: ^ (Sigrihere)\)

/

Jeffrey Himmel


Vice President


Signed and sworn to before me on (date) A p C i \ 1 ; at C O Q M - County, l/QUfvJDV'N (state).

Notary Public.

Coinmission expires:

OFFICIAL SEAL LAUREN PRATSCHER

NOTARY PUBLIC - STATE OF ILUNOIS MY COMMISSION EXPIRES JULY 17,2018 ' ' II • • » I I i ] i » i ^ _

Page 12 of 13


APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D C I T Y OFFICIALS AND DEPARTMENT HEADS



"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Apphcable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[ ] Yes ^ ] No

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is cormected; (3) the name and title of the elected city official or department head to whom such person has a famihal relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13

*The Disclosing Party is not the Applicant nor has direct ownership in the Applicant exceeding 7.5%.


APPENDIX B




[ ] Yes [ ] No

2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ ] Yes [ ] No [ ] Not Applicable




AND AFFIDAVIT

SECTION I - GENERAL INFORMATION


Debevics Diner LTD


Indicate whether the Disclosing Party submitting this EDS is:

1. [ ] the Applicant OR

2. ^ a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the AppUcant in which the Disclosing Party holds an interest: ERIE WELLS LLC

OR 3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 600 W. Jackson #200

Chicago, IL 60661

C. Telephone: 3 1 2 - 4 6 3 - 1 2 1 0 Fax: 3 1 2 - 7 9 8 - 6 7 6 1 Email: JHimmel@Bravorestaurants. com

D. Name of contact person: J e f f r e y Himmel







Vcr. 01-01-12 Page 1 of 13



1. Indicate the nature of the Disclosing Party: [ ] Person ^ ] Limited liability company [ ] Publicly registered business corporation [ ] Limited liability partnership ^ Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)


I l l i n o i s


[ ] Yes [ ] No 1^ N/A




Name Title William J. Kamm President

J e f f r e y Himmel Vice President


Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.


J e f f r e y Himmel 600 W. Jacksom #200 Chicago, IL 60661 25%

Ivan Himmel 600 W. Jackson #200 Chicago, IL 60661 25%

William J. Kamm 7N024 Medinah Rd. P.O. Box 129 Medinah, IL 60157 33.33%

Donna Kamm-YanKala 7N024 Medinah Rd. P.O. Box 129 Medinah, I L 60157 8.33% r h R r y l Kamm WnjriV 7Nn:;!4 Mpdinah Rd. P.O. Rny 12^ Mpdinah, TT, fiOIS? 8 .33%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


[]Yes QJNo






Page 3 of 13





1 ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.





[ ] Yes ^ No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o


1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the AppUcant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13



b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a pubhc (federal, state or local) transacdon or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;









Page 5 of 13










Page 6 of 13



N / A


N / A



[ ] is ^ is not




If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13





[ ] Y e s ^ N o

NOTE: I f you checked "Yes" to Item D . l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D.L , proceed to Part E.



[ ] Yes ^ No

3. I f you checked "Yes" to Item D. L , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:





Page 8 of 13


1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.



NOTE: I f the Matter is federally funded, complete this Section VI. I f the Matter is not federally funded, proceed to Section VII . For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.



N / A

(If no explanation appears or begins on the lines above, or i f the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)


Page 9 of 13

3. The Disclosing Party wi l l submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above.






[ ] Y e s [ ] N o



[ ] Yes [ ] No


[ ] Y e s [ ] N o


[ ] Yes [ ] No


Page 10 of 13

S E C T I O N V I I - A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N , C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E


A. The certifications, disclosures, and acknowledgments contained in this EDS wi l l become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.




D. It is the City's policy to make this document available to the pubhc on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding ehgibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13

F . l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities wi l l not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U . S. General Services Administration.

F.3 I f the Disclosing Party is the Applicant, the Disclosing Party wi l l obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F . l . and F.2. above and wil l not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F . l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.



Debevics Diner LTD A

(PrinJ/or type riam'e of DisQlosing Party)

By:

(Sigh Kef^'

Jeffrey Himmel


Vice President


Signed and sworn to before me on (date) A p O 1 , C 0 O \ ^ County, [ L M M ^ l S (state).

NotaryPublic. <

imission expires:

< » i f t i <f> *

OFFICIAL SEAL LAUREN PRATSCHER

' NOTARY PUBUC - STATE OF ILUNOIS MY COMMISSION EXPIRES JULY 17,2018

Page 12 of 13


APPENDIX A




"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes ^ ] No


Page 13 of 13



APPENDIX B




[ ] Yes [ ] No

2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?



FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.





Letchinger Family LLC




Applicant in which the Disclosing Party holds an interest: wells & Erie LLC OR

3. [ ] a legal endty with a right of control (see Section I I .B . l . ) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 908 North Halsted Street

Chicago, IL 60642

C. Telephone: 312-642-7005 Fax: 312-642-9696 Email: iim(aidlcorp.com

D. Name of contact person: James D. Letchinger







Vcr. 01-01-12 Page l of 13




Person ^ Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)


Illinois-


[ ] Yes [ ] No [ ] N/A



I f the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity Hsted below must submit an EDS on its own behalf.

Name Title James D. Letchinger Manager


Page 2 of 13



Stephanie Letchinger 908 North Halsted Street 100%

Chicago, Illinois 60642

SECTION III - BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


[ ] Yes ) ^No






Page 3 of 13

Name (indicate whether retained or anticipated to be retained)

none

Business Relationship to Disclosing Party Address (subcontractor, attorney,

lobbyist, etc.)


(Add sheets if necessary)

]^Check here i f the Disclosing Party has not retained, nor expects to retain, any such persons or entities.





[ ] Yes y J o [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o


1, Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section I I .B . l . of this EDS:








connection with the Matter, including but not hmited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facihties and equipment; common use of employees; or organization of a business entity following the ineligibiUty of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents"),

Pages of 13










Page 6 of 13



None


None



[ ] is



"We are not and wil l not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affihate of a predatory lender may result in the loss of the privilege of doing business with the City."


Page 7 of 13





[ ] Yes )^No

NOTE: I f you checked "Yes" to Item D. l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D.L, proceed to Part E.



[ ] Yes [ ] No






Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with tlie Matter voidable by the City.

_^C_1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.



NOTE: I f the Matter is federally funded, complete this Section VI . I f the Matter is not federally funded, proceed to Section V I I . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.


1, List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets i f necessary):



Page 9 of 13



5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any .subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.




[ ] Yes [ ] No



[ ] Yes [ ] No


[ ] Yes [ ] No


[ ] Yes [ ] No


Page 10 of 13






C. I f the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other h'ansactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's pohcy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the pubhc on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding ehgibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor arc the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.


F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l. , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION


Letchinger Family LLC


James D. Letchinger


Manager


Signed and sworn to before me on (date) niX\\ SLOi'^ -at l^eH-t- Geunty^ j ^ j j i r w i S (state).

K^Djl/Ul^m-- l ^ ^ r r ^ f Notary Public. "oTFlaArS^Ar

( / w / / i ILLIANA RAMOS | Commiss ion expires: I f 1 0 / / ' ^ . % Notary Public, State of Illinois *

^ ^ i My Commissiori Expires 01 /10/2016 *

Page 12 of 13


APPENDIX A


This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. If is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Parhier thereof currently has a "famihal relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Parly" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aimt or uncle, niece or nephew, gj'andparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Apphcable Party" means (1) all executive officers of the Disclosing Party listed ui Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a hmited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief fmancial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Paity or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an elected city official or department head?

[]Yes IXNo


Page 13 of 13



APPENDIX B




[ ]Yes [ ]No


[ ] Yes [ ] No [ J Not Applicable

3. I f yes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.




SECTION I ~ GENERAL I N F O R M A T I O N


Fyfe's Children's Partnership



OR 2. ^ a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest: ERIE WELLS ^ LLC OR

3. [ ] a legal entity with a right of control (see Section I I .B . l . ) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 630 W. F u l l e r t o n

Chicago, IL 60614

C. Telephone: 773-281-7164 Fax: 773-281-7180 Email: JoanGreco@gmail. com

D. Name of contact person: Joan Greco







Ver. 01-01-12 Page 1 of 13

S E C T I O N II ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S


1. Indicate the nature of the Disclosing Party: [ ] Person [ ] Limited hability company [ ] Publicly registered business corporation [ ] Limited liability partnership [ ] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation

General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)



[ ] Yes [ ] No [ ] N/A



I f the entity is a general partnership, limited partnership, limited liability company, hmited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title Joan Greco Custodian


Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve fu l l disclosure.


Henry Fyfe 630 W. F u l l e r t o n Chicago, I L 60614 33 . 3%

David Fyfe 630 W. F u l l e r t o n Chicago, I L 60614 33 . 3%

Max Fyfe 630 W. F u l l e r t o n Chicago, I L 60614 33 .3%



[ ] Y e s ^ N o

I f yes, please identify below the name(s) of such City elected official(s) and describe .such relationship(s):

S E C T I O N IV - D I S C L O S U R E OF S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as wel] as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.



Page 3 of 13









Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obhgations by any Illinois court of competent jurisdiction?

[ ] Yes ^ No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o



Page 4 of 13












Page 5 of 13










Page 6 of 13

I f the letters "N A," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements.


o e


N)Q^f. •



[ ] is is not


2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:


I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13





[ ] Yes ^ No


2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not con.stitute a financial interest within the meaning of this Part D.


[ ] Y e s ^ N o

3. I f you checked "Yes" to Item D.L , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:





Page 8 of 13


^ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance pohcies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.


S E C T I O N VI ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S



1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying con tacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets i f necessary):

(I f no explanation appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it wil l be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)


Page 9 of 13

3. The Disclosing Party wi l l submit an updated certification at the end of each calendar quarter in which there occurs any event that materiaUy affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above.






[ ] Y e s [ ] N o



[ ] Yes [ ] No


[ ] Yes [ ] No


[ ] Yes [ ] No


Page 10 of 13

S E C T I O N V I I ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N , C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E


A. The certifications, disclosures, and acknowledgments contained in this EDS wi l l become part of any contract or other agreement between the Apphcant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The fu l l text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .



D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives'and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.



Page 11 of 13

I ' . l . f l ic Disclosing Party is not dcliiujiicnl in llic paymeni of any t;i.\ juiniinislcrctl by ilic Illinois

Dcpartniciil of Revenue, nor ;uc the Diselosinij; l';irty or its Al'fiii;i lctl I JIIIIICS liciiiuiuent iii paving any

line, fee, tax or otlicr charge owed lo the City. I liis ineludes, but is :u)t liniiied to, ail water eliarues,

sewer charges, license fees, parking tickets, property taxes or sales taxes.

1'.2 If the Disek)siiig Party is tiie .\pplicanl. liie Disclosing I'arly .iiitl its AM'iliated l.aitities wil l not

use, nor permit their subcontractors to use, any facility listed hv the U S. I : . I ' . A on Ihe federal I.Ncliulcil

Parties List System ("FPLS") maintained by the I . ! . S. General Services .Aiiniinistr.ation.

1'.. I f the i^iselosing I'arly is the Applicant, the Disclosing Party wi l l obtain I'lom any

contractor.s/subcontractors hired or to be hired in connection with the Matter ceitil'ications et|ual in

form and substance to those in I ' . l . ami V.2. aho\e and wil l not, without the prior written coiiseiu ol'the

City, use any sucli cuiitractoi/subcoiilractor that does nol provide such certit'ieaiions oi that the

Disclosing I'arly has reason to lielie\e has nol provided or caimol provide truthl'iil certil'ieations

NOTE: I f the Disclosing i'arly cannot certify as to any of ihe items in i ' . l . , i .2. or i-'.'v above, an explanatory statement must be attached to this HDS.

C E R I I F I C A T I O N

Under penalty of perjury, the person signing below: ( I ) warrants that he/she is authorized to execute

this FDS and Appendi.x A ( i f applicable) on bcha l fof thc Disclosing I'arty, ami (2) warrants that all

certificalions and statements contained in this F.DS and .Appendix A ( i f applicable) are true, accurate

and complete as ol'the ilale furnished to the City.

Joan Greco for Fyfe's Children's Partnership

(Print or tyoe-tiame of Discliwd^ig Party)

Joan Greco


Custodian


Signed and sworn lo before me on (date)

at C i D O ^ County, LCAAAJ()tS~ (state).

Notary Public. ^ 4 OFFICIAL SEAL

Commission expircs:_ (_)U

Page 12 of 13

LAUREN PRATSCHER NOTARY PUBLIC - STATE OF ILLINOIS

MY COMMISSION EXPIRES JULY 17,2018 •iOlS } r,2018 t


APPENDIX A






[ ] Yes ^ ] No

I f yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial reladonship, and (4) the precise nature of such familial relationship.

Page 13 of 13



APPENDIX B




[ ]Yes [ ]No



3. I f yes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings lo which the pertinent code violations apply.


City of Chicago



02015-4177

Meeting Date:

Sponsor(s):

Type:

Title:


5/20/2015


Ordinance

Zoning Reclassification Map No. 4-H at 1911 WCullerton St -App No. 18384 Committee on Zoning, Landmarks and Building Standards

I B 3 8 H

ORDINANCE


SECTION!. Titie 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all of the CI-2, Neighborhood Commercial District, as shown on Map 4-H in the area bounded by:

West Cullerton Street, a line 100 feet West of South Wolcott Avenue, the alley South

and parallel to West Cullerton Street and a line 150 feet West of South Wolcott

Avenue.

To those of B2-2, Neighborhood Mixed-Use District

SECTION 2. This ordinance takes effect after its passage and approval.

Common Address of Property: 1911 West Cullerton Street, Chicago, IL 60608

WRITTEN NOTICE AFFIDAVIT (Section 17-13-0107)

May 13,2015

Honorable Daniel Solis Chairman, Committee on Zoning 121 North LaSalle Street Room 304, City Hall Chicago, Illinois 60602

The undersigned, Daniel G. Lauer, being first duly sworn on oath, deposes and states the following:

The undersigned certifies that he has complied with the requirements of Section 17-13-0107 of the Chicago Zoning Ordinance, by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet in each direction of the lot line of the subject property, exclusive of public roads, streets, alleys and other public ways, or a total distance limited to 400 feet. Said "written notice" was sent by First Class U.S. Mail, no more than 30 days before filing the application.

The undersigned certifies that the notice contained the address of the property sought to be rezoned; a statement of the intended use of the property; the name and address of the applicant; the name and address of the owner; and a statement that the applicant intends to file the application for a change in zoning on or about approximately May 13, 2015.

The undersigned certifies that the applicant has made a bona fide effort to determine the addresses of the parties to be notified under Section 17-13-0107 of the Chicago Zoning Ordinance, and that the accompanying list of names and addresses of surrounding property owners within 250 feet of the subject site is a complete list containing the names and addresses of the people required to be served.

Daniel G. Lauer

Subscribed and Sworn to Before me this IS* day of May, 2015.

Notary Public

OFFICIAL SEAL RENATAPONIWEV KA

LAW OFFICES

DANIEL G. LAUER & ASSOCIATES, P.O. 1424 WEST DIVISION STREET

CHICAGO, ILLINOIS 60642

DANIEL G. LAUER OF COUNSEL

TELEPHONE (773) 862-7200

JAMES R. SETHNA FACSIMILE (773) 862-0600 ROBERT C. STOLLER

HERBERT V. HEDEEN

May 12, 2015

RE: Zoning Change for 1911 West Cullerton Street

Dear Property Owner:

In accordance with the requirements for an Amendment to the Chicago Zoning Ordinance, please be informed that on or about May 13, 2015, the undersigned will file an application for a change in zoning from CI-2, Neighborhood Commercial District to B2-2 Neighborhood Mixed-Use District for the property located at 1911 West Cullerton Street, Chicago, Illinois.

The existing one story structure will remain. The Applicant proposes to convert the existing one story commercial space with basement to two (2) residential dwelling units, with no change to the height or footprint of the building.

The Applicant and Owner is Elizabeth Avina, as beneficiary to the Chicago Title Land Trust Company, successor to the Cole Taylor Bank Trust # 008459 which is located at 10 South LaSalle Street, Suite 2750, Chicago, Illinois 60602 .The contact person for this application is Daniel G. Lauer, 1424 West Division Street, Chicago, Illinois 60642, (773) 862-7200.

Please note that the Applicant is not seeking to rezone or purchase your property. The Applicant is required by law to send this notice because you own property within 250 feet of the property to be rezoned.

Veryjrjaly yours.

Daniel G. Lauer

BOUNDARY & TOPOGRAPHIC SURVEY

l u w nr-r m w , / ? , ^—^ \

.OT 13 *N0 M ( t X C t P I T" t SOWH 26 FECI V SAi3 LOTS) IN A f K t S SLSOIVISICM OF BLOCK t l IN SUCC.VISOh Of ' H t SOUni E«5T OuaRl tR CF SECTION 19. lOWSHiP J9 >iORT», RAHSE 14 EAST OF IHE TIIIRO PniNOPAL UfRIOtAN m COCK COUNTY. ILUNaS

A

I PP3PERTT « E A . 0 - 1 ACRES (4957 89 SOUAHE FEEI)

16' PVIKV 4i;rr

a. MCU' WOHK CC»<PU:rEO OECCtiPER 33 20'.*

• S u R ^ T p>tEPAREO MTHOUt THE AIO CF A Tir.E ALPORT. REFER TO A C U R U x r TITLE REPORT DEED AND tOCAL C O X S FQfl M t EASCUCNT iUfUXNC S E T U A C K S AND OTHER LOCAL RESTRi::Tt3r«s kOT S n O M HEft lX M O K R T r DESdOPTION HOT PRO^QED BT CUEHT

7 SUH«Y PREPAHfO POft LL POPOCATEPETL

0. BULDMC TVS t OlUZHSOiS SHOVM ARE UEASUREC FROU THE OUTSOE "ACE OF THE eiJIOiNG

STATE o r LLINOS ) ) C O L ' N T Y Of COOK )

M : w - r LAND SURVETIHC MC 0 0 HERtBT OtCLAWE THAI « HAVE SWUtT tO T4E ABOVE OESOUED P^CFERTY AND THAT TmS PLAT IS A CORKECT RCPnSCNTATTOh 0^' SAID SURNCY THIS PROFIS5:0»iAL SEmKC CCNFCRUS TO THE CURftCNT L U N d S U-H.UbW S T A . ' U A R C S n » A B O U H O A R Y AhD TOPWRAPKC SUR«Y

L e c e H 0 W-T LAMI SUKVEY1NG MC. ILUNOS

I ] RCMSEO SURVEY J A N U A P Y 5. 3 0 ' 5

^ ^ ^ ^

AND SEA. THIS J i L , , j ! * r : t f ' ' ' : : i i J ^ H ^ ' L .

j j f / >...>s.

BOUNDARY & TOPOGRAPHIC

SURVEY

1911 W. CULLERTON STREET CHICAGO, ILLINOIS WT

W-T LAHD SURVEYING. INC. LAND U O COMSTPIUCTIOH • U R V C T O I I *

t l ( I 7 4 i n i 4 ] U I

C a n w N n I M 4 0 4 W T Exp O O t t U

CFTY OF CHICAGO



1911 WEST CULLERTON, CHICAGO, ILLINOIS

I 9 3 S M

2. Ward Number that property is located in: 25th WARD

3 APPLICANT ^^^^ t)eth Avina, as Beneficiary of the Chicago Title Land Trust Company, successor to the Cole 'I'aylor Bank Trust, Trust #UU84by

ADDRESS 1854 WEST 21st STREET CITY CHICAGO

STATE ILLINOIS ziP CODE60608 PHONE (^^^^ 862-7200

EMAIL ! } ! ^ CONTACT PERSON Daniel G. Lauer, Attorney

4. Is the applicant the owner of the property? YES ^ NO If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application to proceed.

OWNER Chicago Title Land Trust Company, successor to the Cole Taylor Bank, Trust #008459

ADDRESS "" South LaSalle Street, Suite 2750 C I T Y Chicago

STATE JI: ZIP CODE 60602 PHONE (3''^) 223-2195

EMAILQ/a CONTACT PERSON Trust Officer


ATTORNEY DANIEL G. LAUER

ADDRESS 1424 WEST DIVISION STREET

CITY CHICAGO STATE 'LLINOIS zjp CQDE 60642

PHONE (773.) 862-7200 pAX(773) 862-0600 EMAIL [email protected]

6. If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements. Elizabeth Avina

7. On what date did the owner acquire legal tide to the subject property? December 1, 2000

8. Has the present owner previously rezoned this property? If yes, when?

NO

Cl-2, Neighborhood B2-2, Neighborhood

9. Present Zoning District^""^"^^^^^^' District proposed Zoning District Mixed-Use District

10. Lot size in square feet (or dimensions') 4,957.89 (SQ. FT.)

11. Current Use of the property THE HISTORIC SIMON BARUCH BATH HOUSE. •

12. Reason for rezoning the property™^ EXITING STRUCTURE WILL REMAIN, THE REASON FOR THIS ZONING CHANGE

IS TO CONVERT THE COMMERCIAL SPACE WITH BASEMENT TO A TWO (2) DWELLING UNITS .


THE EXISTING ONE STORY STRUCTURE WILL REMAIN. THE APPLICANT PROPOSES TO CONVERT THE EXISTING

ONE-STORY COMMERCIAL SPACE WITH BASEMENT TO TWO (2) RESIDENTIAL DWELLING UNITS, WITH NO

CHANGE TO THE HEIGHT OR FOOTPRINT OF THE BUILDING.

14. On May 14*, 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution i f residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information)

YES NO X


Elizabeth Avina being first duly sworn on oath, states that all of the above statements and the .statemenLs contained in the documents submitted herewith are true and correct.


Subscribed and Sworn to before me this

Notary Public

OFFICIAL SEAL LMGASPERO

NOTARY PUBUC. STATE OF ILUNOIS : MY COMMISSION EXPIRES 07/13/16

For Office Use Only


File Number:.

Ward:





Elizabeth Avina, as Beneficiary of the Chicago Title Land Trust Company, successor to the Cole Taylor Bank Trust, Trust#008459






B. Business address of the Disclosing Party: i854 WEST 21 STREET


C. Telephone: (773) 862-7200 Fax: N/A Email: N/A

D. Name of contact person: DANIEL G. LAUER, ATTORNEY

E. Federal Employer Identification No. (if you have one): jvj/a

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):.

Zoning change of 1911 WEST CULLERTON

G. Which City agency or department is requesting this EDS? DEPARTMENT OF PLANNING AND DEVELOPMENT


Specification # NOT APPI ICARI F and Contract #NOT APPLICABLE

Ver. 01-01-12 Page 1 of 13

SECTION II - D I S C L O S U R E OF OWNERSHIP I N T E R E S T S





Not Applicable


[ ] Yes [ ] No [X] N/A




Name Title Elizabeth Avina Beneficiary


Page 2 of 13



Ellzabetti Avina 1854 West 21st Street, Chicago, IL 60608 100%

SECTION III ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ ] Yes M No

I f yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s): Not Applicable

SECTION IV - D I S C L O S U R E OF SUBCONTRACTORS AND O T H E R R E T A I N E D PARTIES




Page 3 of 13


not an acceptable response. Daniel G. Lauer & Associates 1424 West Division, Chicago, IL 60642 ATTORNEY estimated fee of $5,000.00



SECTION V ~ C E R T I F I C A T I O N S



Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage oh any child support obligations by any Illinois court of competent jurisdiction?



[ ] Yes [ ] No



Page 4 of 13












Page 5 of 13




c. made an admission of such conduct described in a. or b.. above that is a matter of record, but have not been prosecuted for such conduct; or





7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below: Not applicable

Page 6 of 13


8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). Not applicable

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient. Not applicable



[ ] is [ ] is not





Page 7 of 13





[ ] Yes [ ] No

NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D.L, proceed to Part E.



[ ] Yes [ ] No






Page 8 of 13







I . List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets i f necessary):


2. The Disclosing Party has not spent and wil l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or "to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organization described in section 50 1(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 50 1(c)(4) of the Internal Revenue Code of 1986 but has not engaged and wil l not engage in "Lobbying Activities".





[ ]Yes [ ] N o

- I f "Yes," answer the three questions below:


[ ] Yes [ ] No


[ ] Yes [ ] No


[ ] Yes [ ] No

If you checked "No" to question I . or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ~ A C K N O W L E D G M E N T S , C O N T R A C T INCORPORATION, C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E


A. The certifications, disclosures, and acknowledgments contained in this EDS wil l become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.







Page I I of 13

F. l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sevver charges, license fees, parking tickets, property taxes or sales taxes.


F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.


CERTIFICATION

Under penalty of perjury, the person signing below: (I) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.


By: _^^^A,^__C^_£L.^^. (Sign h^re)


Elizabeth Avina, Beneficiary of CTLTC #008459


Signed and sworn to before me on (date) APRIL j C ) at COOK , , County, iLLIN?!. (state).

2015

Commission expires

Notary Public.

Page 12 of 13

OFFICIAL SEAL LMGASPERO

NOTARY PUBUC, STATE OF ILUNOIS ; MY COMMISSION EXPIRES 07/13/16


APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any aldennan, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes [X] No

• If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Not Applicable

Page 13 of 13


APPENDIX B


This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"), It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.


[ ]Yes [X]No


[ ]Yes [^]No [ ] Not Applicable


FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY R E F E l ^ N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.


AND AFFIDAVIT



Chicago Title Land Trust Company, successor to the Cole Taylor Bank Trust, Trust #008459




Applicant in which the Disclosing Party holds an interest: 1611 West Cullerton Ave., Chicago, IL OR


B. Business address of the Disclosing Party: io South Lasaiie, suite 2750


C. Telephone: (312)223-2195 Fax: N/A Email: N/A

D. Name of contact person: Trust Officer

E. Federal Employer Identification No. ( i f you have one): N/a


ZONING CHANGE OF 1911 WEST CULLERTON

G. Which City agency or department is requesting this EDS? DEPARTMENT OF PLANNING AND DEVELOPMENT


Specificafion # NOT APPI ICARI F and Contract #NOT APPLICABLE

Ver. 01-01-12 Page 1 of 13

SECTION II - D I S C L O S U R E OF OWNERSHIP I N T E R E S T S


1. Indicate the nature of the Disclosing Party: [ ] Person [ ] Limited hability company [ ] Publicly registered business corporation [ ] Limited liability partnership [ ] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] No §<] Trust [ ] Other (please specify)


Not Applicable


[ ] Yes [ ] No [X] N/A




Name Title Elizabeth Avina Beneficiary


Page 2 of 13



Elizabeth Avina 1854 West 21st Street, Chicago, IL 100%

SECTION III ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ ] Yes M No

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s): Not Applicable

SECTION IV ~ D I S C L O S U R E OF SUBCONTRACTORS AND O T H E R R E T A I N E D P A R T I E S




Page 3 of 13


not an acceptable response. ZONING AND LAND USE COUNSEL RETAINED BY THE APPLICANT


[x] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or enfities.




Has any person who directly or indirectly owns 10%> or more of the Disclosing Party been declared in arrearage on any child support obligations by any Illinois court of competent jurisdiction?



[ ] Yes [ ] No


1. Pursuant to Municipal Code Chapter 1-23, Arficle 1 ("Arficle l")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: I f Article 1 applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13




c. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Secfion V;


e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violafions, instituted by the City or by the federal government, any state, or any other unit of local government.



connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or enfity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilifies and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible enfity); with respect to Contractors, the term Affiliated Entity means a person or enfity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acfing pursuant to the direcfion or authorizafion of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Pages of 13








6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislafive Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.

7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below: Not applicable

Page 6 of 13


8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or appointed official, of the City of Chicago ( if none, indicate with "N/A" or "none"). Not applicable

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient ( i f none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient. Not applicable



[ ] is [ ] is not


2. I f the Disclosing Party IS a financial insfitution, then the Disclosing Party pledges:

"We are not and wil l not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them wi l l become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory,lender may result in the loss of the privilege of doing business with the City."

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Secfion 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary):

Page 7 of 13





[ ] Yes [ ] No

NOTE: I f you checked "Yes" to Item D.L , proceed to Items D.2. and D.3. I f you checked "No" to Item D.L, proceed to Part E.

2. Unless sold pursuant to a process of competifive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.


[ ] Yes [ ] No

3. I f you checked "Yes" to Item D.L , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:





Page 8 of 13


^ 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.



NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section V I I . For purposes of this Section V I , tax credits allocated by the City and proceeds pf debt obligations of the City are not federal funding.



(I f no explanation appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it wi l l be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and wil l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or enfity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperafive agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organizafion described in secfion 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and wil l not engage in "Lobbying Activities".





[ ] Yes [ ] No



[ ] Yes [ ] No


[ ] Yes [ ] No


[ ] Yes [ ] No


Page 10 of 13

S E C T I O N V I I - A C K N O W L E D G M E N T S , C O N T R A C T INCORPORATION, C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E





C. I f the City determines that any informafion provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement ( i f not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and^releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any inforination submitted in this EDS.

E. The informafion provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the fime the City takes acfion on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13



F.3 I f the Disclosing Party is the Applicant, the Disclosing Party wi l l obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F . l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.


Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A ( i f applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A ( i f applicable) are true, accurate and complete as of the date furnished to the City. Chicago Title Land Trust Company successor, This instrument is exetnrted by the undersigneil Land Tru$t0i, the Cole Taylor Bank Trust #008459 TOt personalty but sdielv as Trustee in the exercise of thepotw

— ' and authority conferred upon and vested in It as such Trus^ (Print or type name of Disclosing Party) It i$ expressly understood and agreed that all the warrantn,

indemnities, representations, covenants, undertakings and agireements herein made on the part of the Trustee are undertaken by it solely in its capacity as Trustee and not pvsonally. No personal liability or personal responsibility is assuned by or shall at any \ m be asserted or enforceable

MM.. • ru-T^r. 3ganst the. Trustee on account of any warranty, indemnity, KELIJA.BEYbR representation, covenant, undertaking or agreement of ttie

Trustee in this instrument. ( P r i n t o r t y p e n a m e o f p e r s o n s i g n i n g ) „,„tora,atloncoma.ne<linth.scerti«catloo

ASS l . VtCft P«fc840fcNT^ beneficiaries of trust no.H 7 ^ ^ ^ ^ •, andWe • — certification is made solely in 'e'-f"fo

(Print or type title of person signing) and no responsibility is assumed bythetrtwiM ^ • ' ^ ^ ^ individual capacity, for the truth or

.".ccuracv of the faets therein stated

Signed and sworn to before me on (date)

at CgOK County, ILLINOIS (state).

Notary Public.


Page 12 of 13


APPENDIX A






[ ] Yes [X] No

If yes, please identify below (1) the name and title of such person, (2) the name of the legal enfity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Not Applicable

Page 13 of 13


APPENDIX B




[ ]Yes [X]No


[ ]Yes [^]No [ ] Not Applicable

If yes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the perfinent code violations apply.


City of Chicago



02015-4178

Meeting Date:

Sponsor(s):

Type:

Title:


5/20/2015


Ordinance

Zoning Reclassification Map No. 9-M at 5800 W Addison St -App No. 18385 Committee on Zoning, Landmarks and Building Standards

ORDINANCE


SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance,

is hereby amended by changing all the B2-2 Neighborhood Mixed-Use District

symbols and indicafions as shown on Map No.9-M in the area bounded by

the alley next north of and parallel to West Addison Street; North Menard Avenue; West Addison Street; and a line 26.75 west of and parallel to North Menard Avenue,

to those of a Cl-2 Neighborhood Commercial District and a corresponding uses district is

hereby established in the area above described.

SECTION 2. This ordinance shall be in force and effect from and after its passage

and due publicafion.

Common Address of Property: 5800 West Addison Street

Written Notice. Form of Affidavit: Section 17-13-0107 May 12, 2015

Honorable Daniel Solis Chairman, Committee on Zoning 121 North LaSalle Street Room 304 - City Hall Chicago, Illinois 60602

To Whom It May Concern:

The undersigned, Nicholas Ftikas, being first duly sworn on oath, deposes and says the following:

That the undersigned certifies that he has complied with the requirements of Section 17-13-0107 of the Zoning Code of the City of Chicago, by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and on the owners of all property within 250 feet in each direction of the lot line of the subject property, exclusive of the public roads, streets, alleys and other public ways, or a total distance limited to 400 feet. Said written notice was or will be sent by USPS First Class Mail no more than 30 days before filing the application.

The undersigned certifies that the notice contained the address of the property sought to be rezoned as 5800 W. Addison, Chicago, Illinois; a statement of intended use of said property; the name and address of the Applicant; the name and address of the owner; and a statement that the applicant intends to file an application for a change in zoning on approximately May 12, 2015.

The Applicant has made a bonafide effort to determine the addresses of the parties to be notified under Section 17-13-0107 of the Zoning Code of the City of Chicago; that the Applicant certifies that the accompanying list of names and addresses of surrounding property owners within 250 feet is a complete list containing the names and last known addresses of the owners of the property required to be served.

Law Offices of Samuel V.P. Banks

y: Nicholas Ftikas, Attorney

Subscribed and Sworn to before me

thi>-J 'L day of , 2015.

Notary

DANIELLE SANDS OFFICIAL SEAL

Notary Public, State of Illinois Mv Commission Expires

October 29, 2018

Via USPS First Class Mail May 12, 2015

PUBLIC NOTICE

Dear Sir or Madam:

In accordance with Amendment to the Zoning Code enacted by the City Council, Section 17-13-0107-A, please be informed that on or about May 12, 2015,1, the undersigned, filed an application for a change in zoning from the B2-2 Neighborhood Mixed-Use District to the Cl-2 Neighborhood Commercial District, on behalf of the Applicant and Property Owner, 5800 Addison, L L C , for the property located at 5800 W. Addison, Chicago, Illinois.

The Applicant is seeking a zoning change in order to permit the establishment of a motor vehicle repair shop at the subject property. The subject property is currently improved with a one-story brick building. The existing building will remain. The interior of the building will be modified and adapted in order to function as a motor vehicle repair shop.

The Applicant and Property Owner, 5800 Addison, LLC, is located at 3519 N. Kostner, Chicago, IL 60641.

I am the contact person for this application. My address is 221 N. LaSalle Street, Chicago, IL 60601. My telephone number is 312-782-1983.

Very truly yours,

LAW OFFICES OF SAMUEL V.P. BANKS

ucholas Ftikas Attorney at Law

*Please note that the Applicant is NOT seeking to purchase or rezone your property.

*The Applicant is required to send this notice because you are shown to own property located within 250 feet of the property subject to the proposed Zoning Amendment.

To whom it may concern:

I, Gabriel Garcia, as Manager and on behalf of 5800 Addison, LLC, Owner of subject

property located at 5800 W. Addison, Chicago, IL, authorize the Law Offices of Samuel

V.P. Banks to file a Zoning Amendment application with the City of Chicago for that

property. >n . /?

Gabriel Garcia 5800 Addison, LLC

FORM OF AFFIDAVIT

Chairman, Committee on Zoning Room 304 - City Hall Chicago, IL 60602

To Whom It May Concern:

I , Gabriel Garcia, on behalf of 5800 Addison, LLC, an Illinois limited liability company,

understand that the Law Offices of Samuel V.P. Banks has filed a sworn affidavit

identifying 5800 Addison, LLC, as the Owner holding interest in land subject to the

proposed zoning amendment for the property identified as 5800 W. Addison, Chicago,

IL.

I , Gabriel Garcia, being first duly sworn under oath, depose and say that 5800 Addison,

LLC, holds that interest for itself and no other person, association, or shareholder.

Date

Subscribed and Sworn to before me t h i s T ^ V o f 4 ^ ^ f < - r 2 0 1 5 .

OFFICIAL SEAL AJUNAGADHWALA

NOTARY PUBLIC - STATE OF ILLINOIS MY COMMISSION EXPIRES:07/25/18

PLAT OF SURVEY 165 (i:>:CEPT TIIE WEST 85 FEET) IN KOESTER AND ZANDER'S ADDITION TO WEST IRVING 1\\RK, A SUBDIVISION

ni- IME SOUTH HALF OF THE NORTHEAST QUARTER OF SECTION 20, TOWNSHIP 40 NORTH, RANGE 13 EAST OF THE TIIIK'l' PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS

16' PUBLIC ALLEY

BITUMINOUS

26.86-GARAGE' /

1 6" tttST / / •

/ GARAGE /

I 6' WEST-^V

16

4-CM

BUILDING-'^ , 2 0" WEST y/

I 0' WEST., /

111 v s ' ^ / -

..^y CONQPETENfe.

FRAME BUILDING

ONE STORY BRICK

BUILDING #5800

LO CM

• EASr WALL OF BUILDING RUNS ALONG LOT LINE

-SOUTH WALL OF BUILDING RUNS ALONG LOT LINE

W. ADDISON STREET

.•..|;I:A 3353 so FT MORE OR LESS

1"!0PFRIV CORNFRS "MOWN H L R L G N N O I U O N U U E N T E D AT THE REQUEST OF THE CLIENT

M:":- IMLE COMWIIyFNT WAS SUPPLIED FOR USE IS THE PREPARATION OF THIS PLAT

PRtPARED FOR. GABRIEL GARCIA

Urchell and .\s.sociiift's. Inc. I.:in(.l .Survx-yins; .Scivicc,>i

PHONE VOB EIES 71M FAX 773 29H 9500

WEDSlTEwnw iirch«lln[idnsjoci8les com

nESICh- HRH RRCIb-TKATION #18•1-004nS^

HO IMPROVEMENTS SHOULD BE CONSTRUCTED ON THE BASIS OF THIS PLM ALONE FIELD MONUMENTATION OF CRITICAL POINTS SHOULD BE ESTABLISHED PRIOR TO COMMENCEMENT OF CONSTRUCTION.

FOR nUILDING LINE AND OTHER RESTRICTIONS NOT SHOWN HEREON REFER TO YOUR DEED, ABSTRACT, TITLE POLICY, CONTRACTS AND LOCAL BUILDING AND ZONING ORDINANCES.

; p / i'.'<OFESsio.\'AL LAND

SURVEYOR STATE Of

•.. ILLINOIS . . ' ^ ^ FIELD WORK COMPLETED. 0 5 / 0 5 / 1 5

THIS PROFESSIONAL SERVICE CONFORMS TO THE CURRENT ILLINOIS STANDARDS FOR A BOUNDARY SURVEY

DATED: 0 5 / 0 5 / 1 5

ROBERT J URCHELL I P L S . No. 3438

UCENSE RENEWAL DATE: NOVEMBER 30 . 2015

SURVEY No . 1 4 - 1 0 - 0 0 8

CITY OF CHICAGO -H^ / 9 3 9 , 5 APPLICATION FOR AN AMENDMENT TO

THE CHICAGO ZONING ORDINANCE

1. ADDRESS of the property AppHcant is seeking to rezone: 5800 W. Addison. Chicago, IL

2. Ward Number that property is located in:

3. APPLICANT: 5800 Addison. LLC ADDRESS: 3519 N. Kostner CITY: Chicago STATE: Illinois ZIP CODE: 60641 PHONE: (312) 782-1983 CONTACT PERSON: Nicholas Ftikas. Esq.

Attorney for Applicant

4. Is the Applicant the owner of the property YES X NO If the Applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application to proceed.

OWNER ADDRES S CITY STATE ZIP CODE PHONE CONTACT PERSON


ATTORNEY Law Offices of Samuel VP Banks ADDRESS 221 N. LaSalle St.. 38"'Floor CITY Chicago STATE: IL ZIP CODE 60601 PHONE: (312) 782-1983 FAX: (312) 782-2433

6. If the applicant is a legal entity (Corporation, LLC, Partnership, etc.), please provide the names of all owners as disclosed on the Economic Disclosure Statements Gabriel Garcia and Carlos Garcia

7. On what date did the owner acquire legal title to the subject property? 2014 1

8. Has the present owner previously rezoned this property? If Yes, when? No

9. Present Zoning: B2-2 Neighborhood Mixed-Use District

Proposed Zoning: Cl-2 Neighborhood Commercial District

10. Lot size in square feet (or dimensions?): 26.86' x 125.11' - Totaling 3,360.45 sq. ft.

11. Current Use of the Property: The property is improved with a one-story brick building.

12. Reason for rezoning the property: To permit the establishment of a motor vehicle repair shop.

13. Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC) The Applicant is seeking a zoning change in order to permit the establishment of a motor vehicle repair shop at the subject property. The subject property is currently improved with a one-storv brick building. The existing building will remain. The interior of the building will be modified and adapted in order to function as a motor vehicle repair shop.

14. On May 14, 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements, Ordinance? (See Fact Sheet for more information)

YES NO X


1, Gabriel Garcia, in my capacity as Manger of 5800 Addison, LLC, an Illinois limited liability company, being first duly sworn on oath, state that all of the above statements and the statements contained in the documents submitted herewith are true and correct.

Stibscribed and Sworn to before me this

' day of < f i f - A l , 2015. 1' OFFICIAL SEAL

AJUNAGADHWALA NOTARY PUBLIC - STATE OF ILLINOIS MY COMMISSION EXPIRES:07/25/18

Notary Public

For Office Use Only


File Number:_

Ward:


AND AFFIDAVIT




Indicate whether the Disclosing Party submitting this EDS is: 1. the Applicant



3. [ ] a legal entity with a right of control (see Section II .B. l . ) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party; .'^ S' I ^ M - |C<^ S T>0T~/l-

C. Telephone: 3a-"? ^X-1 ^ 63 Fax: Z^^'H^I-~L^ ^'^ Email: f\\JL(a) Sc^ jJo<uA^\I gj^. <J^

D. Name of contact person: y Q l T c ^ K o c A - ^ p - ^ x ^ c / y ^ - ^(^-pj-t^ .



G. Which City agency or departnient is requesting this EDS? I ^ P**



Vcr. 01-01-12 Page 1 of 13

SECTION II ~ DISCLOSURE OF OWNERSHIP I N T E R E S T S



Person [ '^ Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)



[ ] Yes [ ] No iVfN/A




Name Title

2. Please provide the following information conceming each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. .Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.

Page 2 of 13



SECTION III ~ BUSINESS RELATIONSHIPS W I T H C I T Y E L E C T E D O F F I C I A L S


[ ]Yes [i^No


dJA

S E C T I O N IV ~ DISCLOSURE OF SUBCONTRACTORS AND O T H E R RETAINED PARTIES


"Lobbyist" means any person or entity who undertakes to influence any legislative or administi-ative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.


Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE: to be retained) " lobbyist, etc.) "hourly rate" or "t.b.d." is





A. COURT-ORDERED CHILD SUPPORT COMPLL^NCE



[ ] Yes [ l ^^o [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Y e s [ ] N o



Page 4 of 13


a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of govemment; ,

b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitmst statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;



e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged ; guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions conceming environmental violations, instituted by the City or by the federal government, any state, or any other unit of local govemment.




Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of'interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local govemment, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;


Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affihated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal govemment or of any state or local government in the United States of America, in that officer's or employee's official capacity;




4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partaers, is barred from contracting with any unit of state or local govemment as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.


6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Govemmental Ethics) of the Municipal Code.


HiAr

Page 6 of 13



'. A / / A -




[ ] is [ ^is not




If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary):

MlA

Page? of 13





[ ] Yes [ 1 ^ 0

NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.



[ ] Yes [ g ^ o



<A/ / A-




Page 8 of 13


The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.


M/^^

SECTION VI ~ C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED MATTERS





2. The Disclosing Party has not spent and wil l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by. applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13



A. The certifications, disclosures, and acknowledgments contained in this EDS wi l l become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 a.nd 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The ful l text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .






Page 11 of 13

F.l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.


F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications,

NOTE: If the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION


(Print orj^pe name of pysclo^ng Party)


*/of pers(

OFFICIAL SEAL AJUNAGADHWAU

NOTARY PUBLIC - STATE OF ILLINOIS MY COMMISSION EXPIRES:07/25/18

(Print or type titl^'of person signing)

Signed and sworn to before me on (date) at C0O ^ County, ( L 1 _(state).

Commission expires: ^ l ' \ .^<^ I X-^f S

Notary Public.

Page 12 of 13


APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "famihal relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.



[ ] Yes [i^No


Page 13 of 13


APPENDIX B




[ ]Yes [wfNo

2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to'Section 2-92-416 of the Municipal Code?

[ ]Yes [ ]No [ < ^ o t Applicable

If yes to (I) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDDC B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

City of Chicago



02015-4179

Meeting Date:

Sponsor(s):

Type:

Title:


5/20/2015


Ordinance

Zoning Reclassification Map No. 3-1 at 2440 W Division St App No. 18386 Committee on Zoning, Landmarks and Building Standards

ORDINANCE


SECTION I . Title 17 of the Municipal Code of Chicago, the Chicago Zoning

Ordinance, is hereby amended by changing all of the B l - I , Neighborhood Shopping

District symbols and indications as shown on Map No. 3-1 in area bound by

A line 100 feet west of and parallel to North Artesian Avenue, the alley next north and

parallel to West Division Street, a line 75 feet west of and parallel to North Artesian

Avenue, West Division Street

to those of a Bl-2, Neighborhood Shopping District.

SECTION 2. This ordinance takes effect after its passage and approval.

Common Address of Property: 2440 W Division

"WRITTEN NOTICE" FORM OF AFFIDAVIT

(Section 17-13-0107)

May 20, 2015

Honorable Daniel Solis Chairman, Committee on Zoning 121 N. LaSalle Street Room 304, City Hall Chicago, Illinois 60602

The undersigned, _ deposes and says the following:

Thomas S. Moore _, being first duly swom on oath,

That the undersigned certifies that he or she has complied with the requirements of Section 17-13-0107, of the Chicago Zoning Ordinance, by sending written notice to such owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet in each direction of the lot lines of the subject property, exclusive of public roads, street, alleys and other public ways, or a total distance limited to 400 feet. Said "written notice" was sent by First Class U.S. Mail, no more than 30 days before filing the application.

The undersigned certifies that the notice contained the address of the property sought to be rezoned; a statement of the intended use of the property; the name and address of the applicant; the name and address of the owner; and a statement that the applicant intends to file the application for a change in zoning on approximately May 20, 2015.

The imdersigned certifies that the applicant has made an bona fide effort to determine the addresses of the parties to be nofified under Secfion 17-13-0107 of the Chicago Zoning Ordinance, and that the accompanying list of names and addresses of surrounding property owners within 250 feet of the subject site is a complete list containing the names and addresses of the people required to be served.

Subscribed and avvbnijo^efpi^ me th)s ^ 0 day of K{du^ 20 ( \

Notary Public

OFFICIAL SEAL SONSERESE HATCH

NOTARY PUBUC-STATE OF ILLINOIS MY COMMISSION EXPIRES:07/18/18

ANDERSON <& MOORE, VX:, AT ri >\;s]:\s .\ r L.wv

111 WivS'i- VVA.SIiiN(iT(.)N S'ru>i;i2i'. Si. i i i; 1720

CiiKj.Mio, ILLINOIS iH}(i02

T H O M A S S . >1O()KM.:

. I A . M ' , F . - \ M : ) 1 ' ; W S ( : ) \ T I ; L I - ; I : M I ( ) . N - E ( 3 1 2 ) L>51-15()()

F.ACSi .MiLi ; c j l i i ) i.>5:l.-150t»

May 20, 2015

To Property Ovmer:

In accordance with requirements for an Amendment to the Chicago Zoning Ordinance, specifically Section 17-13-0107, please be informed that on or about May 20, 2015, the undersigned will file an application for a change in zoning from BI- I to Bl-2 on behalf the applicant, Gibbons Construction, LLC for the property located at 2440 W Division

The applicant seeks to construct a 4 story building with one commercial unit on the first floor and 3 residential dwelling units on the 2"**, 3' '' and 4" floors. The height of the building will be 48 ft.

The owner and/or applicant of the property is Gibbons Construction, LLC whose business address is 3720 N Sheffield, Chicago, IL 60613. You can reach Patrick Gibbons at 773-935-1696 if you have any questions.

I am the attomey for the applicant and can be reached at the above number i f you have any questions.

Please note the applicant is not seeking to rezone or purchase your property. The applicant is required by law to send this notice because you own property within 250 feet of the property to be rezoned.

Thomas S. Moore

TSM:sh

Plat of Survey Central Survey Company, LLC, 6415 N. Caldwel l Ave., Chicago, Illinois 60646-2713 Phone (773) 631-5285 www.Gentralsurvey.com Fax (773) 775-2071

Legal Description

Lot 22 in Block 7 in the Resubdivision of the South part of Blocks 5 , 6 , 7, and 8 in Winslow and Jacobson's Subdivision of the Southeast % of the Northeast Vt of Sect ion 1 , Township 39 North, Range 13 East of the Third Pnncipal Meridian, in Cook County, Illinois

Commonly Known as: 2440 W. Division St., Chicago, Illinois Area of Land Descr ibed: 3,134 Sq. Ft.

NW Face Cham Unk Fence Post 1 TQ'E &03rs

Found PK Nail 6 0' N & On Line Extended

N Face Chain Unk Fence Past 0 16'S

Pound PK Nfiil 6.0' N & On Line Extended

/

WE Face Cham Unk Fence Post 1.20'E 4 0.32'S

E Face Cham Unk Fence Post 1.60' E

0 03' N & 1.73' W

Found Cross 2 0' S & On Line Extended

Concreto Curb

Found Cross 2 0' S & On Line Extended

W. Division Street

Leaend

N s E W. (TYP) Rec Meas St. Ave.

North South East

West Typical Record

Measure Street

Avenue

; 0 0 1 ' = 1/8' 1 Decimal/lnch Conversions 1 0.02' = IM- 0 08'= f 0 58' = 7-0.03' = 3/8' 0.17' =2- 0 67' = 8" 0.04' = 1/2' 0 25' = 3- 0 75' = 9-0.05' = SIS- 0 33' = 4- 0 83 = 10-0 06' = 3lf 0.42- = 5' 0 92'= I f 0 07' = 7IS- 0 W = 6- 1 00'= 12-

State of Illinois

County of Cook ) )S.S.

This professional service conforms to current Illinois minimum standards

for a boundary survey

NOTE: Property corners were NOT staked per customer. 20 Feet

Ordered Bv. Strauss Reallv Ltd Order Number- 2440A Assume no dimension from scaling upon this plat. Compare all points before building and report any difference at once For building restrictions refer to your abstract, deed, contract and local ordinances

Central Survey LLC does hereby certify that an on the ground survey per record descnption of the land shown hereon was performed on November 5, 2014 and that the map or plat hereon drawn is a correct representation of said survey. When bearings are shown the bearing base is assumed Dimensions are shown in feet and hundredths and are correct at a temperature of 68° Fahrenheit.

Dated this 5th day of November 2014 William R W e b b P L S #2190 (exp 11/30/2016) Prolessional Design Firm Land Surveying LLC («1B4-004-13)

CITY OF CHICAGO


1. ADDRESS of the property Applicant is seelcing to rezone:

2440 W Division

2. Ward Number that property is located in: 26

8 3

3. APPLICANT Gibbons Construction LLC

ADDRESS 3720 N Sheffield


PHONE 773-935-1696 CONTACT PERSON Patrick Gibbons

4. Is the Applicant the owner of the property? YES X NO If the Applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the applicant to proceed.

OWNER

ADDRESS

CITY STATE ZIP CODE

PHONE CONTACT PERSON


ATTORNEY Thomas S. Moore

ADDRESS 111 W Washington Suite 1720 CITY Chicago


PHONE 312-251-1500 FAX 312-251-1500

6. If the applicant is a legal entity (Corporation, LLC, Partnership, Etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements.

Patrick Gibbons

Nora Gibbons

7. On what date did the owner acquire legal title to the subject propertv?08-18-2010

8. Has the present owner previously rezoned this property? If Yes, when? No

9. Present Zoning District Bl-1 Proposed Zoning District Bl-2

10. Lot size in square feet (or dimensions?) 25x125

11. Current Use of the property Vacant

12. Reason for rezoning the subject property: To construct a 4 story building with one commercial unit on the first floor and 3 residential dwelling units on the 2—, 3— and 4-.floors. The height of the building will be 48 ft.

13. Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC) To construct a 4 story building with one commercial unit on the first floor and 3 residential dwelling units on the 2—. 3- and 4- floors. The height of the building will be 48 ft.

14. On May 14" , 2007, the Chicago City Council passed the affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution i f residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information).

YES NO X


Patrick Gibbons _, being first duly swom on oath, states that all of the above statements and the statements contained in the documents submitted herewith are true and correct.

ignature of Applicant

Subscribed and Swom to before me this f a ^ day of_

Notary Public

^ , 20^ C OFFlCiALSEAL

SONSERESE HATCH NOTARY PUBLIC-STATEOF ILLINOIS


File Number:

For Office Use Only

Ward:


AND AFFIDAVIT

SECTION I -GENERAL INFORMATION

A. Legal name of Disclosing Party submitting this EDS. Include d/b/a/ if applicable:

Gibbons Construction, LLC


Indicate whether Disclosing Party submitting this EDS is: 1. [ X] the Applicant


Applicant in which Disclosing Party holds an interest: OR

3. [ ] a specified legal entity with a right of control (see Section II.B.l .b) State the legal name of the entity in which Disclosing Party holds a right of control:

B. Business address of Disclosing Party: 3720 N Sheffield Chicago. IL 60613

C. Telephone: 773-935-1696 Fax: Email gibbonswarrenfSjgmail.com

D. Name of contact person: Patrick Gibbons - - - -


F. Brief description of contract, transition or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

Zoning Change-2440 W Division

G. Which City agency or department is requesting this EDS? Department of Planning & Development Bureau of Zoning



Ver. 01-01-12 Page 1 of 13


A. NATURE OF DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party: ] Person [ X] Limited liability company* ] Publicly registered business corporation [ ] Limited liability partnership* ] Privately held business corporation [ ] Joint venture* ] Sole proprietorship [ ] Not-for-profit corporation ] General partnership* (Is the not-for-profit corporation also a 501(c)(3))? ] Limited partnership* [ ] Yes [ ] No ] Trust [ ] Other (please specify)

*Note B.l.b below


Illinois


[ ] Yes [ ] No [X] N/A


1. List below the full names and title of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

If the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf

Name Title Patrick Gibbons Member

Nora Gibbons Member


Page 2 of 13

Interest of a member or manager in a limited liability company, or interest of a beneficiary of a tmst, estate or other similar entity. If none, state "None." NOTE: Pursuant to Secfion 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the

Disclosing party

Patrick Gibbons 3720 N Sheffield. Chicago. IL 60613 50%

Nora Gibbons 3720 N Sheffield. Chicago. IL 60613 50%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

Has the Disclosing Party has a "business relationship." as defined in Chapter 2-156 of the Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ ] Yes [X] No


SECTION IV - DISCLOSURE OF SUBCONTRACTORS & OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attomey, lobbyist, accountant, consultant and any other person or entity whom the Disclosing party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party, must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE: to be retained) lobbyist, etc) "hourlyrate" or "t.b.d." is


Anderson & Moore-Attorney 111 W Washington Ste 1720; Chicago. IL 60602 Estimated to be

$5.000.00

(Add sheets if necessary)

[ ] Check here if the Disclosing party has not retained, nor expects to retain, any such persons or entities.

SECTION V —CERTIFICATIONS


Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compliance with their child support obligations throughout the term of the contract.



If "Yes," has the person entered into a court-approved agreement for payment of all support owned and is the person in compliance with that agreement?

[ ] Yes [ ] No


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting the EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicated or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certification 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities identified in Section II .B.l . of this EDS:

a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of govemment;

b. have not, within a five-year period preceding that date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;

c. are not presently indicted for or criminally or civilly charges by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;

d. have not, whhin a five-year period preceding the date of this EDS, had one or more public transaction (federal, state or local) terminated for cause or default; and

e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions conceming environmental violations, instituted by the City or by the federal govemment, any state, or any other unit of local govemment.


• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not limited to any persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity) with respect to Contractors, the temi Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13


a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal govemment or of any state or local govemment in the United Stated of America, in that officer's or employee's official capacity;

b agreed or colluded with other bidders, or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or



4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local govemment as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United Stated of America that contains the same elements as the offense of bid-rigging or bid-rotating.

5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons Lists, the Unverified List, the Entity List and the Debarred List.

6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (inspector General) and 2-156 (Govemmental Ethics) of the Municipal Code.


N/A

Page 6 of 13



N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if non, indicate with a "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.

N/A



[ ] is [X] is not


2. If the Disclosing Party IS a financial institution, then the Disclosing party pledges:


If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages of necessary):

Page 7 of 13





[ ] Yes [X]No

NOTE: If you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. If you checked "No" to Item D.L, proceed to Part E.



[ ] Yes [X] No

3. If you checked "Yes" to Item D.l. , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:





Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery, or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provide coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.


SECTION VI -- CERTIFICATIONS FOR FEDERALLY-FUNDED MATTERS

NOTE: I f the Matter is federally funded, complete this Section VI. I f the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allowed by the City and proceeds of debt obligations of the City are not federal funding.


1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter: (Add sheets as necessary):

(If no explanation appears or begins on the lines above, or if the letters "NA" or if the work "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify and federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Intemal Revenue code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Intemal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

5. If the Disclosing Party is the applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . tlirough A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.




[]Yes [ ] No


1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2).

[ ] Yes [ ] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No


[ ] Yes [ ] No


Page 10 of 13


The Disclosing Party understand and agrees that:


B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N.


C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in cormection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Intemet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Intemet, in response to a Freedom of Information Act request, or otherv ise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INTELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2. If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility on the U. S. E.P.A. on the federal Excluded Parties List System ("EPLS) maintained by the U.S. General Services Administration.

F.3. If the Disclosing Party is the Apphcant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.


CERTIFICATION


(SigiThefe) Patrick Gibbons

(Print or type name of person signing) Member


Signed and sworn to before me on (date)_ at Cook Count^, Ilji?iois.

Notary Public

OFFlCiALSEAL SONSERESE HATCH

NOTARY PUBUC - STATE OF ILLINOIS MY COMMISSION EXPIRES;C7/18/18

Commission expires:_ Page 12 of 13


APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related, by blood or adoption, to the mayor, any alderman, the city clerk, the city treasurer, or any city department head as parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Part" means (1) all corporate officers of the Disclosing Party, if the Disclosing Party is a corporation; all partners of the Disclosing party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and member of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes [ X] No


Page 13 of 13


APPENDIX B




[^Yes [ / ]NO


I I Yes O N° [ 3 Applicable



Page 14 of 14

City of Chicago



02015-4180

Meeting Date:

Sponsor(s):

Type:

Title:


5/20/2015


Ordinance

Zoning Reclassification Map No. 7-L at 2820 N Cicero Ave and 4800-4830 W Diversey Ave - App No. 18387 Committee on Zoning, Landmarks and Building Standards

^ / 83

O R D I N A N C E


SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is

hereby amended by changing all the RS-3 Residential Single-Unit (Detached Housing) District

symbols and the Bl-1 Neighborhood Shopping District indications as shown on Map No. 7-L in

the area bounded by

West Wolfi-am Street; North Cicero Avenue; West Diversey Avenue; a line 402.24 feet west of and parallel to North Cicero Avenue; the alley next north and parallel to West Diversey Avenue; and the alley next west and parallel to North Cicero Avenue,

to those of a Bl-1 Neighborhood Shopping District and a corresponding uses district is hereby

established in the area above described.

SECTION 2. This ordinance shall be in force and effect from and after its passage and due

publication.

Common Address of Property: 2820 North Cicero Avenue and 4800-4830 West Diversey

Avenue, Chicago, Illinois

AFFIDAVIT OF WRITTEN NOTICE (Section 17-13-0107)

May 13,2015

Honorable Daniel S. Solis Chairman, Committee on Zoning 121 North LaSalle Street Room 304, City Hall Chicago, Illinois 60602

RE: 2820 N. Cicero Avenue and 4800-4830 W. Diversey Avenue

The undersigned, Ryan Sullivan, being first duly swom on oath deposes and states the following:

The undersigned certifies that he has complied with the requirements of Section 17-13-0107 of the Chicago Zoning Ordinance, by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet in each direction of the lot line of the subject property, exclusive of public roads, streets, alleys and other public ways, or a total distance limited to 400 feet. Said written notice was sent by First Class U.S. Mail, no more than 30 days before filing the application.


The undersigned certifies that the applicant has made a bona fide effort to determine the addresses of the parties to be notified under Section 17-13-0107 of the Chicago Zoning Ordinance, and that the accompanying list of names and addresses of surrounding property owners within 250 feet of the subject site is a complete list containing the names and addresses of the people required to be served.

KOZONIS & ASSOCIATES, LTD.

By: Ryan Sullivan, Attomey

3 ubscrihed and Swom to before me this 2 d f l _ d a y of H a o ; 20 I S

TAT** '

Notary Public

'OFFlCiALSEAL LINDA NALLEY

NOTARY PUBLIC, STATE OF ILUNOIS ;My Commisaion Expires 04/14/2019

PUBLIC NOTICE

VIA FIRST CLASS U.S. MAIL

May 14, 2015

Dear Sir or Madame:

In accordance with the requirements for an Amendment to the Chicago Zoning Ordinance, specifically Section 17-13-0107, please be informed that on or about May 14, 2015, the undersigned \N\\\ file an application for a change in zoning from RS-3 Residential Single-Unit (Detached House) District and Bl-1 Neighborhood Shopping District to B1-1 Neighborhood Shopping District on behalf of the Applicant and Owner, Diversey Cicero Developers LLC, for the property located at 2820 N. Cicero Avenue and 4800-4830 W. Diversey Avenue.

The property is currently a commercial, retail shopping center (strip center) and the use of the property will not change. The Property contains no dwelling units, 103 parking spaces, approximately 30,000 sf of commercial space, and building height is approximately 30 ft. The applicant seeks a zoning change to clarify the split zoning of the property, and to permit the construction of a 582 SF vestibule entrance, 1,026 SF cooler, and new masonry fence to the existing building at the northwest corner of the Property. The current tenant uses are carry-out pizza restaurant, furniture rental store, and grocery store.

The Applicant and Owner, Diversey Cicero Developers LLC, is located at 4849 N. Milwaukee Avenue, #302, Chicago, Illinois 60630.

The contact person for this application is Ryan Sullivan, 4849 N. Milwaukee Avenue, #300, Chicago, Illinois, (773) 545-9607.

Very truly yours,

KOZONIS & ASSOCIATES LTD.

Ryan Sullivan, Esq.

***Please note that the applicant is not seeking to rezone or purchase your property.

***The applicant is required by law to send this notice because you own property within 250 feet of the property to be rezoned.

if 1 idl'l i'lElB

I"

CITY OF CHICAGO


8 3 8 - 7

ADDRESS of the property Applicant is seeking to rezone:

2820 N. Cicero Avenue and 4800-4830 W. Diversey Avenue

2.

3.

Ward Number that property is located in: 31st Ward

APPLICANT Diversey Cicero Developers LLC

ADDRESS 4849 N. Milwaukee Avenue. Ste 302 CITY Chicago

STATE Illinois . ZIP CODE 60630 . PHONE (773^545-9607

EMAIL rsullivan(S)kozonislaw.com CONTACT PERSON Ryan Sullivan (Attorney for Applicant)

Is the applicant the owner of the property? YES_ NO If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the oNvner allowing the application to proceed.

OWNER • ' '

ADDRESS CITY

STATE ZIP CODE

EMAIL CONTACT PERSON

PHONE


ATTORNEY Kn7nnifi K Assnriatfts I tri

ADDRESS 4849 N Milwaukee Avenue, Ste 300 • •

CITY Chicago STATE Illinois ZIP CODE 60630

PHONE (77.- ) .S4f -9fin7 FAX (773) 49fi-Sfi17 EMAIL rsullivan(S)kozonislaw.com

6. If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements.

Loukas Ko7nniR .

7. On what date did the owner acquire legal title to the subject property? 2013


No

9. Present Zoning District RS-3 and Bl-t . . . - Proposed Zoning District B1-1

10. Lot size in square feet (or dimensions) 68,056 SF

11. Current Use of the property Commercial Retail Shopping Center (strip center)

12. Reason f o r r e z o n i n g the p r o p e r t y Thp prnpRrty (strip r.ftntpr) is a partially 7nnfirt R-q-.- anri partially ynnaci B l - 1 .

The rezoning will clarify the property's zoning and correct the split zoning issue.

13. Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC) The property is currently a commercial, retail shopping center (strip center) and the use of the property will not change. The current tenant

uses are carry-out pizza restaurant, furniture rental store, and grocery store. The applicant seeks a zoning change to clarify the split zoning of

trie property, and to perniii the construction of a 582 5F vestlBule entrance, i ,026 SF cooler, ana new masonry fencB to the exiaiing building at the northwfest comer of the Property. The Property contains no dwelling units, 103 parking spaces, approx 30,000 sf of commercial space,

and building height is approx. 30 ft

14. On May 14"", 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information)

YES NO X


Demetrios Kozonis _, being first duly sworn on oath, states that all of the above statements and the statements contained in the documents submitted herewith are true and correct.

Subscribed and Sworn to before me this /S-fh day of M .

Notary Public

•<tV»^»tf>g«<W#l»»^ -

"OFFlCiALSEAL" LINDA NALLEY

NOTARY PUBLIC, STATE OF ILLINOIS My Commission Expires 04/14/2019


For Office Use Only

File Number:.

Ward:

l-y":,,.... ;





Diversey Cicero Developers LLC


Indicate whether the Disclosing Party submitting this EDS is: 1. ^ ] the Applicant


Applicant in which the Disclosing Party holds an interest: ' OR


B. Business address of the Disclosing Party: 4849 N. Milwaukee Avenue, Ste 302


C. Telephone: (773) 545-4200 Fax: (773) 545-0147 Email:

D. Name of contact person: Demetrios Kozonis '



Zoning amendment application for the property located at 2820 N Cicero Ave, and 4800-4830 W. Diversey Ave.

G. Which City agency or department is requesting this EDS? Dfipartment of Planning and Development



Vcr. 01-01-12 Page 1 of 13

SECTION H - DISCLOSURE OF OWNERSHIP INTERESTS



Person [x| Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)


Illinois


[ ] Yes [ ] No ^ ] N/A




Name Title

Demetrios Kozonis Manager


Page 2 of 13


Name Business Address Percentage Interest in the 4849 N. Milwaukee Ave., Ste 302 Disclosing Party

Loukas Kozonis Chicago, Illinois 60630 100%

S E C T I O N III -- BUSINESS R E L A T I O N S H I P S WITH C I T Y E L E C T E D O F F I C I A L S


[ ] Yes bdNo


S E C T I O N IV -- D I S C L O S U R E OF S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the natiire of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.



Page 3 of 13


Kozonis & Associates, Ltd.

Business Address

Relationship to Disclosing Party Fees (indicate whether

(subcontractor, attorney, lobbyist, etc.)

Attorney (retained)


$?,500 (estimated) 4849 N. Milwaukee Avenue, Ste 300




S E C T I O N V - C E R T I F I C A T I O N S




[ ] Yes ^ ] No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o



Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II .B. l . of this EDS:








connection with the Matter, including but not limited to all persons or legal ehtities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the



Page 5 of 13



b. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or otherwise; or '




5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Departihent of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List; the Entity List and. the Debarred List.



Page 6 of 13






[ ] is ^ ] is not




If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary):

Page 7 of 13





[]Yes k]No

NOTE: If you checked "Yes" to Item D.l . , proceed to Items D:2. and D.3. I f you checked "No" to Item D.l . , proceed to Part E.

2. Unless sold pursuant to a process of competitive bidding, or otherwise perrhitted, no' City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D. '


[ ] Yes [ ] No

3. If you checked "Yes" to Item D.l . , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:





Page 8 of 13





NOTE: If the Matter is federally funded, complete this Section VI. I f the Matter is not federally funded, proceed to Section Vl l . For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.



(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)


Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501 (c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".





[]Yes [ ] N o


1. Have you developed and do you have on file affirmative action prograrhs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] N o


[ ] Yes [ ] No


[ ] Yes [ ] No


Page 10 of 13

S E C T I O N V I I - - A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N , C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E


A. The certifications, disclosures, and acknowledgments contained in this EDS wil l become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.





E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1 -23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13

F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.


F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION


Diversey Cicero Developers LLC (Print or type name of Disclosing Party)

(Sign heri

Demetrio.s Ko7onis


Manager


Signed and swom to before me on (date) \^ChA . o ^ f ^ , at O o a k County, V (^tjite)-

/ . X ^ K ' b ^ . 0 Notary Public.

Commission expires: :

Page 12 of 13


APPENDIX A




"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section U.B:l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" rneans the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes Ix] No

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and tide of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B




[ ]Yes [^3 No

If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ ] Yes [ ] No fy^] Not Applicable



City of Chicago



02015-4181

Meeting Date:

Sponsor(s):

Type:

Title:


5/20/2015


Ordinance

Zoning Reclassification Map No. 12-L at 5148-5158 S Long Ave-App No. 18388 Committee on Zoning, Landmarks and Building Standards

OJRDINANCE

BE IT ORDAINED BY THE CITY COUNCIL OF TJHE CITY OF CHICAGO:

SECTION 1. Title 17 of the IVIunicipal Code of Chicago, the Chicago Zoning Ordinance, is hereby amended by changing all of the RS-2 Residential Single-Unit (Detached House) District symbols and indications as shown on Map No. 12-L in area bounded by

. West 52nd Street; South Long Avenue; A line 97.00 feet north of and parallel of West 52nd Street: the public alley next west of and parallel to South Long Avenue

To those of a RS-3 Residential Single-Unit (Detached House) District.

SECTION 2. This ordinance shall be in force and effect from and after its passage and due publication.

Common Address of Property: 5148-5158 S. Long, Chicago, Illinois 60638

May 14, 2015

L A W O F F I C E O F

C H R I S T O P H E R K O C Z W A R A , P . C . 5 8 3 8 S O U T H A R C H E R A V E N U E

C H I C A G O , I L L I N O I S 6 0 6 3 8

E M A I L : I N F O @ K O C Z W A R A L A W . C O M

W W W . K O C Z W A R A L A W . C O M

T E L 7 7 3 . 7 6 7 . 5 4 2 2 • F A X 7 7 3 . 7 6 7 . 5 4 2 3

Honorable Daniel Solis Chairman, Committee on Zoning 121 North LaSalle Street Room 304, City Hall Chicago, Illinois 60602

Dear Chairman Solis:

The undersigned, Christopher Koczwara, being first duly swom on oath, deposes and says the following:

The undersigned certifies that he has complied with the requirements of Section 17-13-0107 of the Chicago Zoning Ordinance, by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the owners of all property within 250 feet in each direction of the lot line of the subject property, exclusive of public roads, streets, alleys and other public ways, or a total distance limited to 400 feet. Said "written notice" was sent by First Class U.S. Mail, no more than 30 days before filing the application.


The undersigned certifies that the application has made a bona fide effort to determine the addresses of the parties to be notified under Section 17-13-0107 of the Chicago Zoning Ordinance, and that the accompanying list of names and addresses of surrounding property owners within 250 feet of the subject site is a complete containing the names and addresses of the people required to be served.

st pher Koczwara

Subscribed and Swom to before me This 14th day of May, 2015

Notary Public

'oFpraALSEAL MONiKAGGALlCA

MHTiRY PUSLIC - STATE OF ILLiNOlS

LAW O F F I C E O F

C H R I S T O P H E R K O C Z W A R A , P.C. 5 8 3 8 S O U T H A R C H E R A V E N U E

C H I C A G O , I L L I N O I S 6 0 6 3 8

E M A I L : I N F O @ K O C Z W A R A L A W . C O M

W W W . K O C Z W A R A L A W . C O M

T E L 7 7 3 . 7 6 7 . 5 4 2 2 • FAX 7 7 3 . 7 6 7 . 5 4 2 3

May 13,2015

Dear Property Ovraer or Resident:

In accordance with the requirements of an Amendment to the Chicago Zoning Ordinance, specifically Secfion 17-13-0107, please be informed that on or about May 20, 2015,1, the undersigned, will file an applicafion for a change in zoning from RS-2 Residential Single-Unit (Detached House) District to RS-3 Residential Single-Unit (Detached House) District on behalf of Lukasz & Barbara Uscinski for the property located at 5148-5158 S. Long Ave, Chicago, Illinois 60638.

The property measuring 97 feet width by 125 feet depth will be subdivided into three lots: one lot will measure 37 feet width by 125 feet depth, the second lot will measure 30 feet width by 125 feet depth, and the third lot will measure 30 feet width by 125 feet depth.

The exisfing single family residence at 5158 S. Long Avenue, Chicago, Illinois 60638 will remain unchanged. It sits on the lot measuring 37 feet width x 125 feet depth.

The applicant intends to use the two unimproved lots in order to construct a new single family residence with two car parking on each of the two lots. Each of the lots will measure 30 feet width X 125 feet depth.

The applicant is Lukasz and Barbara Uscinski, 5158 S. Long Ave., Chicago, Illinois 60638. The contact person for this application is Christopher Koczwara, Attomey at Law, 5838 S. Archer Avenue, Chicago, Illinois 60638, 773-767-5422.

The owner of the property is Lukasz and Barbara Uscinski, 5158 S. Long Ave., Chicago, Illinois 60638. The contact person for this application is Christopher Koczwara, Attomey at Law, 5838 S. Archer Avenue, Chicago, Illinois 60638, 773-767-5422.

Please note that the applicant is not seeking to rezone or purchase your property. The applicant is required by law to send this notice because you own property within 250 feet of the property to be rezoned.

fistop

PLAT OF SURVEY OF

LOTS 21, 22, 23, AND 24 IN BLOCK 17 IN CRANE VIEW ARCHER AVENUE HOME ADDITION TO CHICAGO, BEING A SUBDIVISION OF THE WEST HALF OF THE WEST HALF OF SECTION 9, TOWNSHIP 38 NORTH, RANGE 13, EAST OF THE THIRD PRINCIPAL MERIDIAN, EXCEPT THE NORTH 9.225 ACRES THEREOF AND EXCEPT ALSO A STRIP OF LAND 66 FEET WIDE ACROSS THE WEST HALF OF THE SOUTHWEST QUARTER OF SAID SECTION 9 TO BE USED FOR RAILROAD PURPOSES AS DESCRIBED IN DEED TO JAMES H. MAHER DATED APRIL 20, 1896 AND RECORDED MAY 4, 1896 IN BOOK 5728, PAGE 51, AS DOCUMENT 2383034, IN COOK COUNTY, ILUNOIS.

NORTH

I 1 SCALE: 20'

BEARING SYSTEM: ASSUMED

BLOCK 17

-FOUND NOTCH

o

o 05

0 96'

-ADJACENT CONCRETE 0 05' NORTH

S 89- 50' 11" E

= 125.70'

-CHAIN LINK FENCE 0.3' SOUTH 0.1' EAST

LOT 21

LOT 22

-CHAIN LINK FENCE 0.1' EAST

LOT 23

S o

LOT 24

2 2 . 5 8 ' .CM,

N 89" 50 11 W

.R. & M. = 1 2 5 . 7 0 CHAIN LINK FENCE 0 1' NORTH

(33')

-FOUND NOTCH

CONCRETE WALK

-FOUND NOTCH 2 0' SOUTH

CO

FOUND NOTCH

-W—52ND STREET-(66' R O.W.)

NOTE R. & M DENOTES RECORD AND MEASURED DISTANCES RESPECTIVELY BEARINGS SHOWN HEREON ARE MEASURED

CLIENT CHRISTOPHER KOCZWARA (ATTORNEY AT LAW) JOB ADDRESS. 5148-5158 SOUTH LONG AVENUE, CHICAGO. IL JOB NO 15-04-026

S.H. CAMPBELL LAND SURVEYING

8432 SOUTH 84TH AVENUE HICKORY HILLS, IL. 60457

TEL: (708) 594-5370 FAX: (708) 594-5369

NO IMPROVEMENTS SHOULD B l MADE ON THE BASIS OF THIS PLAT ALONE FIELD MONUMENTATION OF CRITICAL POINTS SHOULD BE ESTABLISHED PRIOR TO COMMENCEMENT Of ANY AND ALL CONSTRUCTION FOR BUILDING LINES, EASEMENTS AND OTHER RESTRICTIONS NOT SHOWN HEREON. REFER TO YOUR DEED, ABSTRACT, TIILE POLICY, CONTRACTS AND LOCAL BUILDING AND ZONING ORDINANCES

so.- :<"'. ~cr>: 0 3 5 - 0 0 3 1 3 2 " . r i

PROFESSIONAL z ^ : LAND SURVEYOR - ^ S i5: \STATE OF ILLINOIS .-co f

.••••o>-

AREA SURVEYED = 12.193 SQ. FT.

State of Illinois 1 ^„ > SS

County of Cook J

I, Scott H Campbell, an Illinois Professional Land Surveyor, do hereby certify that 'This professional service conforms lo Ihc current Illinois minimiim standards foi a boundaiy survey", and that the plat hereon drawn is a correct representation of said survey

Illinois Professional Larid Suiveyor No 3132 License expires November 30,2016

Date fieldwork performed 04 -21 -2015

City of Chicago y i / J ^ ^ ' ^ ' " ' ^

Application for an Amendment to the Chicago Zoning Ordinance


5148-5158 S. Long Ave.. Chicago. IL 60638

2. Ward Number that property is located in: 14th Ward

3. APPLICANT Lukasz Uscinski

ADDRESS 5158 S. Long Ave.

CITY Chicago. IL 60638

PHONE 630-508-1998 CONTACT PERSON Lukasz Uscinski

3. APPLICANT Barbara Uscinski

ADDRESS 5158 S.Long Ave.


PHONE 630-508-1998 CONTACT PERSON Lukasz Uscinski

Is the Applicant the owner of the property? YES NO If the Applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the Applicant to proceed.

OWNER

ADDRESS

CITY STATE ZIP CODE,



ATTORNEY Christopher Koczwara

ADDRESS 5838 S. Archer Avenue


PHONE 773-767-5422 FAX 773-767-5423 EMAIL [email protected]

6. I f the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements.

NA ,

7. On what date did the ovmer acquire legal title to the subject property? The single family residence was purchased on December 16. 2013 and the two vacant lots were purchased on December 30. 2014.

8. Has the present owner previously rezoned this property? If yes, when? NO

9. Present Zoning District RS-2 Proposed Zoning District RS-3

10. Lot size in square feet (or dimensions?) 97' x 125.00': 12.193 square feet

11. Current Use of the Property. The Property is currently used as a single family residence on a lot measuring 97 x 125.

12. Reason for rezoning the property. To subdivide the property into three lots, with the existing single family residence to remain on the 37 x 125 lot and to construct two new single family residences with two car parking on the two newly subdivided lots, each lot measuring 30 x 125.


To allow the use of the existing single family residence on a lot measuring 37 x 125 and also to allow the construction of two new single family residences on each lot, with each lot measuring 30 x 125.

14. On May 14" , 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution i f residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information)

YES NO X


Lukasz Uscinski and Barbara Uscinski, being first duly swom on oath, states that all of the above statement and the statements contained in the documents submitted herewith are true and correct.


ignature of Applicant

Subscribed and Swom to before me this - ^ a y of ^ ^ J ^ ,2015 \

N O T A R Y ' I ^ B L I C

For Office Use Only


File Number:

Ward:


AND AFFIDAVIT

SECTION I - GENERAL INFORMATION


Lukasz U s c i n s k i


Indicate whether the Disclosing Party submitting this EDS is: 1. [xl the Applicant



3. [ ] a legal entity with a right of control (see Section ILB. l . ) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 5158 S. Long Ave

Chicago, I L 60638

C. Telephone: 630-508-1998 fax: Email:

D. Name of contact person: Lukasz U s c i n s k i



Z o n i n g Amendment o f 5148-5158 S. Long

G. Which City agency or department is requesting this EDS? Z o n i n g Commit tee


Specification # NA and Contract #

Ver. 01-01-12 Page 1 of 13

SECTION II -- D I S C L O S U R E OF OWNERSHIP I N T E R E S T S


1. Indicate the nature of the Disclosing Party: [ % Person [ ] Limited liability company [ ] Publicly registered business corporation [ ] Limited liability partnership [ ] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)


NA


[]Yes []No y^lA


1. List below the fu l l names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).


Name Title NA


Page 2 of 13



NA

S E C T I O N III ~ BUSINESS RELATIONSHIPS W I T H C I T Y E L E C T E D O F F I C I A L S


[ ] Y e s


SECTION IV -- D I S C L O S U R E OF SUBCONTRACTORS AND O T H E R R E T A I N E D P A R T I E S


"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.


Page 3 of 13


Chris Koczwara

Business Address

Relationship to Disclosing Party Fees (indicate whether (subcontractor, attorney, lobbyist, etc.)

A t t o r n e y


$ 2 , 5 0 0 : 0 0

5838 S. A r c h e r n o t y e t p a i d

C h i c a g o , I L 60638







[ ] Y e s [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guiU of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and,acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13










Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the inehgibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affihated Entity or any


Page 5 of 13










Page 6 of 13



Lukasz U s c i n s k i 5158 S. L o n g , C h i c a g o , I L 60638




[ ] is ' ^



"We are not and wil l not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them wi l l become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."


m : —

Page 7 of 13





^ ^ e s [ ] No




[ ]Yes


Name Lukasz U s c i n s k i

Business Address Nature of Interest J o i n t owner o f

5158 S, Long property w i t h w i f e

Chicago, I L 60638




Page 8 of 13


JC 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.


NA

S E C T I O N V I - C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S




NA



Page 9 of 13

3. The Disclosing Party wi l l submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above.






[ ] Yes [ ] No



[ ] Yes [ ] No


[ ] Y e s [ ] N o


[ ] Y e s [ ] N o

I f you checked "No" to question 1. or 2. above, please provide an explanation: NA

Page 10 of 13

SECTION V I I -- A C K N O W L E D G M E N T S , C O N T R A C T INCORPORATION, C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E



B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The ful l text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N .



D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in. connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.



Page 11 of 13

F. I . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.



NOTE: I f the Disclosing Party cannot certify as to any of the items in F . l . explanatory statement must be attached to this EDS.

F.2. or F.3. above, an


Under penalty of perjury, the person signing below: ( I ) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as of the date furnished to the City.

Lukasz Use ins hi


(Sign here)

iu^a<^z Uscinski (Print or type name of person signing)


Notary Public.

Commission expires: '-""^^/^^/^^^y^^

Page 12 of 13


APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or depaitment head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Paity or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section ILB.l.a., i f the Disclosing Pai ty is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an electe^ city official or department head?

[ ] Yes

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is cormected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B




[ ]Yes X l N o


[ JYes [ ]No ^^f>4^ot Applicable






A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f appUcable:

Barbara Uscinski


Indicate whether the Disclosing Party submitfing this EDS is: 1. M the Applicant




B. Business address of the Disclosing Party: 5158 S. Long Ave

Chicago, I L 60638

C. Telephone: 630-508-1998 Fax: Email:

D. Name of contact person: Lukasz U s c i n s k i


F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable);

Zoning 'Amendment o f 5148-5158 S. Long

G. Which City agency or department is requesting this EDS? Z o n i n g Commit tee


Specification # NA and Contract #

Ver. 01-01-12 Page 1 of 13



1. Indicate the nature of the Disclosing Party: [ % Person [ ] Limited liability company [ ] Publicly registered business corporation [ ] Limited liability partnership [ ] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporafion also a 501 (c)(3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)

2. For legal entifies, the state (or foreign country) of incorporafion or organization, if applicable:

NA


[ ] Yes [ ] No y^lA




Name Title NA


Page 2 of 13



NA

S E C T I O N I I I - BUSINESS RELATIONSHIPS W I T H C I T Y E L E C T E D O F F I C I A L S


[ ] Y e s


S E C T I O N IV ~ D I S C L O S U R E OF SUBCONTRACTORS AND O T H E R R E T A I N E D P A R T I E S


"Lobbyisf means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.


Page 3 of 13


Chris Koczwara

Business Address

Relationship to Disclosing Party Fees (indicate whether (subcontractor, attorney, lobbyist, etc.)

A t t o r n e y


$ 2 , 5 0 0 . 0 0

5838 S. A r c h e r n o t y e t p a i d

C h i c a g o , I L 60638







[ ] Y e s [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] N o


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article l")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the AppHcant nor any controlling person is currently indicted or charged with, or has admitted guilt o f or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13









connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly; controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the inehgibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any


Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affihated Entity, or an Affihated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:









Page 6 of 13



Lukasz U s c i n s k i 5158 S. Long , C h i c a g o , I L 60638




[ ] is "y^^

a "financial institution" as defined in Section 2-32-45 5(b) of the Municipal Code.

2. I f the Disclosing Party IS a financial instimtion, then the Disclosing Party pledges:

"We are not and wil l not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is,, and none of them wi l l become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."


NA —

Page 7 of 13





" ^ e s [ ] No




[ ] Y e s


Name Business Address Nature of Interest Lukasz Uscinski J o i n t owner of

5158 S. Long ^ property w i t h w i f e

Chicago, IL 60638




Page 8 of 13


JC 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records,


NA

S E C T I O N VI ~ C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S




NA

(If no explanation appears or begins on the lines above, or i f the letters "N A" or i f the word "None" appear, it wi l l be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and wi l l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by appUcable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party wil l submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A. 1. and A.2. above.






[ ] Y e s [ ] N o



[ ] Yes [ ] No


[ ] Yes [ ] No


[ ] Yes [ ] No

I f you checked "No" to question 1. or 2. above, please provide an explanation: NA

Page 10 of 13

SECTION VII ~ A C K N O W L E D G M E N T S , C O N T R A C T INCORPORATION, C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E



B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The fu l l text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N .






Page 11 of 13





CERTIFICATION



CxTSien here) ^Sign here)



Signed and sjvorn to before menon4date)

a t _ 4 ^ 1 County, ( / l ^ _ L (state). 1 OFFlCiALSEAL

. X ^ ^ ^ ^ \ CHRISTOPHERKXg^ ^ ^

{ ^ ^ 7 X ^ ^ ^ ^ 2 ^ Notary Public. \

Commission expires: /^(i/'^^^^)^^

Page 12 of 13


APPENDIX A




"Applicable Party" means (1) all executive officers of the Disclosing Party hsted in Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently have a "familial relationship" with an electe^ city official or department head?

[ ] Yes

I f yes, please identify below (1) the name and titie of such person, (2) the name of the legal entity to which such person is coimected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B




[ ]Yes


[ ]Yes [ ]No J^i<j4ot Applicable

3. I f yes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.


City of Chicago



02015-4182

Meeting Date:

Sponsor(s):

Type:

Title:


5/20/2015


Ordinance

Zoning Reclassification Map No. 6-H at 1951 W22nd PI -App No. 18389T1 Committee on Zoning, Landmarks and Building Standards

ORDINANCE


SECTION 1. That the Chicago Zoning Ordinance be amended by changing all the current RS-3 Residential Single-Unit (Detached House) District symbols and indications as shown on Map No. 6-H in the area bounded by:

West 22"** Place; a line 100.00 feet east of South Damen Avenue; the public alley next south of West 22"** Place; and a line 75.00 feet east of South Damen Avenue

to those of a B2-2 Neighborhood Mixed-Use District which is hereby established in the area described above.

SECTION 2. This Ordinance shall be in force and effect from and after its passage and due publication.

May 13,2015

Chairman, Committee on Zoning Room 304, City Hall Chicago, Illinois 60602

Chairman:

The undersigned, Rolando R. Acosta, being first duly sworn on oath, deposes and say the following:

That the undersigned certifies that he has complied with the requirements of the Chicago Zoning Ordinance, Title 17, Section 13-0107-A of the Municipal Code of Chicago, by serving written notice by USPS first class mail, to the owners of all property within 250 feet in each direction of the lot lines of the subject property, the boundaries of which are:

West 22"** Place; a line 100.00 feet east of South Damen Avenue; the public alley next south of West 22"'* Place; and a line 75.00 feet east of South Damen Avenue

exclusive of public roads, streets, alleys and other public ways, or a total distance limited to 400 feet, and that the notice contained the address and description of the property which is the subject of the application under the Chicago Zoning Ordinance; a statement of the intended use of said property; the name and address of the applicant; and a statement that the applicant intends to file said application on approximately May 13, 2015; that the applicant has made a bona fide effort to determine the addresses of the parties to be notified under the cited section of the Municipal Code of the City of Chicago; that the applicant certifies that the accompanying list of names and addresses of surrounding property owners within 250 feet, recognizing the above limits, is a complete list containing the names and last know addresses of the owners of the property required to be served and that the applicant has furnished in addition a list of the persons so served.

By:

Subscribed and swom to before me this May 13,2015.

OFFICIAL SEAL MELINDA LAWRENCE

Notary Public - State of Illinois My Commission Expires Sep 5,2017

ft

i.

..1...-. 'Lf.:-

May 13,2015

Dear Sir or Madam:

Please take notice that under the Chicago Zoning Ordinance an application (the "Applicafion") to change the RS-3 Residential Single-Unit (Detached House) District to those of a B2-2 Neighborhood Mixed-Use District for the area which is bounded by:

West 22""* Place; a line 100.00 feet east of South Damen Avenue; the public alley next south of West 22"'' Place; and a line 75.00 feet east of South Damen Avenue

(hereafter the "Property") will be filed on or about May 13, 2015 with the Department of Plarming and Development, City of Chicago by Velazquez Properties, LLC, 2028 W. 23' '' St., Chicago, IL 60608 (hereinafter the "Applicant"). The address of the Property is 1951 W. 22"** PI., Chicago, IL. The Applicant is the owner of the Property.

The Property currently is improved with a two-story building containing a vacant ground floor space and two residential dwelling units on the upper floors with two parking spaces and no loading. The Application, i f approved, will allow the Applicant to use the existing ground floor space for a floral design and retail store. No additions to the existing building are planned.

This notice is required by the Chicago Zoning Ordinance, Title 17, Section 17-13-0107-A of the Municipal Code of Chicago. It is being sent to you because you appear as a taxpayer of record within 250 feet of the Property. The Application will not rezone your property. Any questions regarding this notice may be direct to the undersigned at 312-636-6937.

Sincerely,

R. Acosta, Attomey for the Applicant

NARRATIVE 1951W. 22"d Place

TYPE I REGULATIONS

Narrative: The subject property contains approximately 3,105 sq. ft. of land and is currently improved with a tv^^o-story building containing a vacant ground floor space of approximately 1,950 sq. ft., two residential dwelling units on the second floor and two parking spaces. The Applicant proposes to use the existing ground floor space for a floral design and retail store. No exterior additions are proposed and the existing two residential dwelling units and two parking spaces will be retained. MLA- \ jS50 FAR: 1.26

FLOOR AREA: Approximately 3,900 sq. ft.

Residential Units: Two

Height: 25.00 ft.

Setbacks: ZZ"'' PI. Property Line: None East Property Line: None West Property Line: None South Property Line (alley]: 38.21 ft.

Parking Spaces: Two

Loading: None

. ^ X

' ',1

4, I

O r--O

in ^

\ w / I

O i l

NORTH

FAX: (773)282-9424 nuTuurveyt28S@Abcglob«l.nc(

PROFESSIONAL DESIGN FIRM No. 184-003233

PLAT OF SURVEY OF

LOT 52 IN BLOCK 4 IN WALKER'S DOCK ADDITION TO CHICAGO, SEIKO A SUBDIVISION OF THE EAST l i NORra OF THE RTVER OF SECTION 30, TOWNSHIP 39 NORTH, RANGE 14, EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.

TOTAL LAND AREA =3,105 sq.ft.

w. 22ND. PL.

-CORNER OF Sujc Il95llj . ' . 2 5 . 0 0 ."'^f ILOG. #19!

L E G E N D

E.F.P.

O.F.P.

O.BP.

O.C.P.

E.C.

- CHAIN UNK FENCE

• WOOD FENCE

• IRON FENCE

- CONCRETE PAVEMENT

- ENCLOSED FRAME PORCH

- OPEN FRAME PORCH

- OPEN BRKK PORCH

- OPEN CONC. PORCH

- EDGE OF CONCRETE

84293 SCALE: 1 |NCH=

FIELDWORK CCMPLETION DATE

16 FEET

10 MARCH 2015

ORDERED S Y : -HAROLD JAIMES

THIS PnOFCSSIOHAL SERVICE COnrOfOitS TO T>4C OKWENT ILLINOIS MINIMJU STANDARDS FOR A BOUNDARY SURVEY.

FOR BUILOJNG LINES, CASEMENTS AND OTHER ReSTRlCTIOrJS NOT SHOWN HEREON. REFER TO YOUR DEED, TITLE POLICY AND LOCAL ZQNtNQ OAQttUMCC. CTC.

LEGAL DESCRIPTION NOTED ON THIS PLAT WAS PROVIDED DY THE

CLIENT AND MUST BC COMPAREO WITH DEED AND/OR TITLE POLICY.

NO CCONens WCRC M O N U M N T E O PCH CUSTOMER REQUEST.

ALL DIMENSIONS ARC SKCMN IN FEET AND DECIMAL PARTS THEREOF.

State of Illinois SS

County of Cook

Wo, M M Surveying Co., Inc., do hereby cert i fy that we have surveyed the above described property and that the plat hereon drawn is o cor rect representation of said survey.

Slgnature:-

Data: MARCH 11,2015

REG. ILL. Land Surveyor No, 3 5 - 3 7 5 8

UC. EXP. NOVEMBER 30, 2016

NORTH

nunsurvcy i ^v:i t)Cj;too«i.nc(

PROFESSIONAL DESIGN FIRM No. 184-003233

P L A T OF S U R V E Y OF

LOT 52 IN BLOCIC 4 IN WALKER'S DOCK ADDITION TO CHICAGO, BEING A SUBDIVISION OF THE EAST '/i NORTH OF THE lUVER OF SECTION 30, TOWNSHIP 39 NORTH, RANGE 14, EAST OF THE THIRD PRINCIPAL MERIDIAN. IN COOK COUNTY. ILLINOIS.

TOTAL LAND AREA = 3,105 sq.ft.

W. 22ND. PL.

; IS..AT FROPE(nY CORdEri^; \25.00 .CORNER CF BLDG. |1951.--

r r i s 0.O2'E & aQ3N. -. .•>S-IRON FENCE POST'IS 1, .y^-y- 0.29'e. a I.OJ H.- •

L E G E N D

E.F.P

0,F.P.

o.a.p. o.e.p. E.C.

' CHAIN UNK FENCE

• WOOD FENCE

• IRON FENCE

- CONCRETE PAVEMENT

- ENCLOSED FRAME PORCH

- OPEN FRAME PORCH

- OPEN BRICK PORCH

- OPEN CONC. PORCH

- EDGE OF CONCROE

J i ^ / i30:.-"or.'CH \ o ;

84293 SCALE: 1 |NCH=

FfELOWORK

CCWPLETIOH DATE

16

10 MARCH 2015

ORDERED BY: HAROLD JAIMES

THIS PROFESSIONAL SERVICE CONFORMS TO THE CURRENT ILLINOIS MINIMUM STANDARDS FOR A DOUNOARY SUNVCY. FOfi SUILDINC LINES. CASEMENTS AND OTHER RESTRICTIONS NOT SHOWN HEREON, REFER TO YOUR aECO, TITLE POLICY AND LOCAL ZONING OflOINANCE. ETC.

LEGAL DESCRIPTION NOTED ON THIS PLAT WAS PROVIDED DV THE

CLIENT AND MUST BE COMPARED WITH DEED AND/OR TITLE POLICC,

NO CORNERS WERE MGNUNENTED PER CUSTOMER REQUEST.

ALL DIMENSIONS ARE SHOWN IN FEET AND DECIMAL PARTS THEREOF.

State of Illinois SS

County of Cook

We, M M Surveying Co., Inc., do hereby certify that we have surveyed the above described property and that the plat hereon drawn is a cor rect representation of said survoy.

Signature;-

Date:-MARCH 11,2015

REG. ILL. Land Surveyor No. 3 5 - 3 7 5 8

UC. EXP. N0VEM8ER 30, 2016

CITY OF CHICAGO



1951 W. 22"'' PI.

1 8 3 9 ^

2. Ward Number that property is located in: _ 25th

3. APPLICANT Velazquez Properties, LLC

ADDRESS 2028 W. 23'" St.

CITY Chicago STATE__JL ZIP CODE 60608

PHONE 312-636-6937 CONTACT PERSON Rolando R. Acosta

4. Is the Applicant the owner of the property? YES X N0_ If the Applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the applicant to proceed.

OWNER

ADDRESS

CITY STATE ZIP CODE



ATTORNEY Rolando R. Acosta

ADDRESS 1030 W. Chicago Ave. CITY Chicago


PHONE 312-636-6937 FAX

6. If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements.

Javier Velazquez, Zenia Ruiz and Rosalva Ruiz

7. On what date did the owner acquire legal title to the subject property?

8. Has the present ovmer previously rezoned this property? I f Yes, when?

No

9. Present Zoning District RS-3 Proposed Zoning District _ B2-2

10. Lot Size in square feet (or dimensions) 3,105 sq. ft.

11. Current Use of the property A two-story building with vacant ground floor space and two residential dwelling units on the upper floor, with two parking spaces.

12. Reason for rezoning the property: Authorize the use of the ground floor space for a

floral design and retail space.

13. Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC) The existing two-story

building will remain with the ground floor approximately 1,950 sq. ft. space used for a floral design and retail store and the upper floor containing two residential dwelling units, with two parking spaces and no loading berth.

14. On May 14"', 2007, the Chicago City Council passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information)

YES NO X


I, being first duly swom on oath, states that all of the above statements and the statements contained in the documents submitted herewith are true and correct.


Subscribed and Sworn to me before this L2th dft^ o j ^ May

For Offic'e Use Only /


File Number:_

Ward:


AND AFFIDAVIT



Velazquez Properties, LLC


Indicate whether the Disclosing Party submitting this EDS is: 1. the Applicant




B. Business address of the Disclosing Party: 2028 W. 23rd St.

Chicago, IL 60608

C. Telephone: 312-636-6937 fax: Email:[email protected]

D. Name of contact person: ^^Q'^"^^ ^ - ^^^^ta



Rezoning of 1951 W. 22nd PI.

G. Which City agency or department is requesting this EDS? DPD



Ver. 01-01-12 Page 1 of 13




Person XI Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)


Illinois


[ ] Yes [ ] No pg N/A


1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholdcr(s).


Name Title

Javier Velazquez Manager

Zenia Ruiz Manager

Rosalva Ruiz Manager


Page 2 of 13



Javier Velazquez 2028 W. 23rd St., Chicago, IL 60608 41%

Zenia Ruiz 2028 W. 23rd St., Chicago, IL 60608 41%

Rosalva Ruiz 2131 W. Coulter St., Chicago, IL 60608 18%

SECTION III ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D OFFICIALS


[ ] Yes bd No






Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attomey, paid or estimated.) NOTE: to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is


Rolando R. Acosta 1030 W. Chicago Ave.. Chicago. IL 60642 Atty $3.000 (est.)







[ ] Yes Ixl No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] No


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13


a. arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of govemment;


c. arc not presently indicted for, or criminally or civilly charged by, a govemmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;


e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal govemment, any state, or any other unit of local govemment.






Page 5 of 13






4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local govemment as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.




Page 6 of 13



None


None



[ ] is is not



"Wc arc not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. Wc understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."


Page 7 of 13





[ ] Yes S(] No




[ ] Yes [ ] No

3. If you checked "Yes" to Item D. l . , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:





Page 8 of 13





NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section VII . For purposes of this Section VI , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.





Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Intemal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".





[ ] Yes [ ] No



[ ] Yes [ ] No


[ ] Yes [ ] No


[ ] Yes [ ] No


Page 10 of 13




B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.






Page 11 of 13

F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.


F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful cerdfications.


CERTIFICATION


Velazquez Properties, LLC (Print or type naipejif Disclosing Party)

>ign here)


Manager (Print or type title of person signing)

Signed and sworn to before me on (date) May 12, 2015 at Cook ^ County, fllinois (state).

^Xt^otary Public.

Paae 12 of 13


APPENDIX A



Under Mimicipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general parmership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes [X] No


Page 13 of 13


APPENDIX B




[ ]Yes [X]No


[ ]Yes [ ]No DC] Not Applicable



City of Chicago



02015-4189

Meeting Date:

Sponsor(s):

Type:

Title:


5/20/2015


Ordinance

Zoning Reclassification Map No. 9-H at 3530 N Lincoln Ave -App No. 18390 Committee on Zoning, Landmarks and Building Standards

ORDINANCE I M ^ ^ D ^ - r e :

BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO: SECTION 1. Title 17 of the Municipal Code of Chicago, Chicago Zoning Ordinance, is hereby-amended by changing all of the Cl-2 Neighborhood Commercial District symbols and indications as shown on Map No. 9-H in area bound by

A southwesterly line 43.21 feet long and perpendicular to North Lincoln Avenue starting at a point 351.35 feet northwest of the north line of West Cornelia Avenue (as measured along the southwest line of North Lincoln Avenue) and ending at a point 43.21 feet east of the east line of North Ravenswood Avenue at a point 293.50 feet north of the north line of West Cornelia Avenue (as measured along the east line of North Ravenswood Avenue); a perpendicular line to North Ravenswood Avenue 43.21 feet long 293.50 feet north of and parallel to the north line of West Comelia Avenue (as measured along the east boundary line of North Ravenswood Avenue); North Ravenswood Avenue; a perpendicular line to North Ravenswood Avenue 60.82 feet long starting at a point 218.50 feet north of the north line of West Comelia Avenue (as measured along the east line of North Ravenswood Avenue) and ending at a point 60.82 feet east of the east line of North Ravenswood Avenue; A northeasterly line perpendicular to North Lincoln Avenue 60.82 feet long starting at a point a point 60.82 feet east of the east line of North Ravenswood avenue and 218.50 feet north of the north line of West Cornelia Avenue (as measured along the east line of North Ravenswood Avenue) and ending at the southwesterly line of North Lincoln Avenue at a point 276.35 feet northwest of the north line of West Cornelia Avenue (as measured along the southwest line of North Lincoln Avenue); North Lincoln Avenue.

to those of a C1-3 Neighborhood Commercial District

SECTION 2. This ordinance takes effect after its passage and due publication

Common Address of Property: 3530 N. Lincoln Avenue

AFFIDAVIT OF COMPLIANCE

Honorable Daniel S. SoUs Chairman, Committee on Zoning 121 North LaSalle Street Room 304 - City Hall Chicago, Illinois 60602

The undersigned, John A. Fritchey, being first duly swom on oath, deposes and states the following:

The tmdersigned certifies that he has complied with the requirements of Section 17-13-0107 of the Chicago Zoning Ordinance, by sending written notice to such property owners who appear to be the owners of the property within the subject area not solely owned by the applicant, and to the ovraers of all property within 250 feet in each direction of the lot line of the subject property, located at 3530 North Lincoln Avenue, exclusive of public roads, streets, alleys and other public ways, or a total distance limited to 400 feet. Said written notice was sent by First Class U.S. Mail, no more than 30 days before-filing the application.

The undersigned certifies that the notice contamed the address of the property sought to be rezoned; a statement of the intended use of the property; the name and address of the applicant; the name and address of the owner; and a statement that the applicant intends to file the application for a change in zoning on approximately May 13,2015.

The undersigned certifies that the applicant has made a bona fide effort to determine the addresses of the parties to be notified under Section 17-13-0107 of the Chicago Zoning Ordinance, and that the accompanying Hst of names and addresses of surrounding property owners within 250 feet of the subject site is a complete list containing the names and addresses of the people required to be served.

John A. Fritchey

Subscribed and Swom to before me this 13* Day of May, 2015 B LUEHRSEN

OFFICIAL SEAL Notary Public. State ot Illinois Mv Cotmnissibn Expires

J»nuary 29, 2(rl7

Notary Public

F /^rMVTCTTT T'TXTO T T ' T i 758 N . L M I R A B E E ST., SUITE 824 — U U M b U L l l M L r L r l D . CHICAGO, ILLINOIS 60654

312.593.5400

[email protected]

May 13,2015

Dear Property Owner:

In accordance with the requirements for an Amendment to the Chicago Zoning Ordinance, specifically

Section 17-13-0107, please be informed that on or about May 13, 2015, this firm v^U file an

application for a change in zoning from a Cl-2 Neighborhood Commercial District to at CI-3

Neighborhood Commercial District on behalf of the applicant VGS Holdings LLC, for the property

located at 3530 North Lincoln Avenue. The rezoning is sought in order to allow for the establishment

of a four-story, 50' high, 15 dwelling unit building with groimd floor retail space and 18 off-street

parking spaces.

The property is ovmed by VGS Holdings, LLC, whose principals are Yaroslav Kot and Vadim

Davidiouk, 2100 West Erie Street, Chicago, IL 60612. I am the contact person for the apphcant. My

address and phone number are set forth at the top of this letter.

PLEASE NOTE THAT THE APPLICANT IS NOT SEEKING TO PURCHASE OR REZONE YOUR PROPERTY, BUT ONLY TO LEGALIZE THE USE OF ITS OWN PROPERTY FOR THE PROPOSED PURPOSE. THE APPLICANT IS REQUIRED BY LAW TO SEND YOU THIS NOTICE BECAUSE YOU ARE LISTED AS THE TAXPAYER OF RECORD OF PROPERTY LOCATED WITHIN 250 FEET OF THE EXISTING PROJECT. NO ACTION IS REQUIRED ON YOUR PART.

Sincerely,

F4 CONSULTING LTD.

John A. Fritchey

Honorable Daniel S. Sohs Chairman, Committee on Zoning, Landmarks and Building Standards 121 North LaSalle Street Room 304 - City Hall Chicago, Illmois 60602

To Whom It May Concem:

I , Yaroslav Kot, state that I have authorized F4 Consulting, Ltd. to file an application

identifying VGS Holdings LLC as the entity holding interest in the land subject to the

application for an amendment to the Chicago Zoning Ordinance for the property commonly

known as 3530 North Lincoln Avenue, Chicago, Illinois.

I depose and say that VGS Holdings LLC holds such interest for itself and no other person,

association, or shareholder.

Signature

Yaroslav Kot Print Name

April 13,2015 Date

Subscribed and Swom to Before Me

T h i s ^ j ^ O ^ April, 2015

Notary Public

B LUEHRSEN OFFICIAL SEAL

Notary Public, State of Illinois My CoBT^nission Expires

January 29, 2(rl7

I f f U.!:5k i>l

N. RAVENSWOOD AVENUE

- Z "7" I

ACOCD ' . ^ I

C O -

r ^ 5 o b 3S > z £ S °

zlfr. O ^ o i S b

T. > ^ PI H m S

z 5 5 C ri 5

IS 5S 8=5 5? 3? ats U ft I i i i i l i I il i l l l 1 S 11 si 11 3 ss if Pi

I u n it = P is ! SI E

SES *:e g«

n r m P II II J5 2 s

mm ••

i ill ~' P S F; 2

5 i |

I 2 '

EfiSES

g S g g i

z o c o

TO 7* z

III

i l l

iSic

o

CITY OF CHICAGO



3530 North Lincoln Avenue

2. Ward Number that property is located in: 47

3. APPLICANT VGS Holdings LLC

ADDRESS 2100 West Erie Street

CITY Chicago I STATE Illinois ZIP CODE 60612

PHONE 847-401-5786 CONTACT PERSON Yaroslav Kot

Is the applicant the owner of the property? YES X NO If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allovsing the application to proceed. j

OWNER i

ADDRESS

CITY : STATE ZIP CODE_

PHONE I CONTACT PERSON


ATTORNEY F4 Consulting Ltd. - John Fritchey

ADDRESS 758 N. Larrabee Street #824 CITY Chicago

CITY Chicago STATE Illinois ZIP CODE 60654

PHONE 312-593-5400 FAX N/A

If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names of all owners as disclosed on the Economic Disclosure Statements.

Yaroslav Kot

Vadim Davidiouk

7. On what date did the ovraer acquire legal title to the subject property? 2014


No

9. Present Zoning District Cl-2 Proposed Zoning District Cl-3

10. Lot size in square feet (or dimensions) 7.822.89 s.f.

11. Current Use of the Property Vacant

12. Reason for rezoning the property To allow for establishment of a mixed-use retail and commercial establishment.


To allow for establishment of a four-story, 50' high, 15 dwelling unit building with approximately 4600 sq.ft. of grovmd floor retail space and 18 off-street parking spaces.

14. On May 14' , 2007, the Chicago City Coimcil passed the Affordable Requirements Ordinance (ARO) that requires on-site affordable housing units or a financial contribution if residential housing projects receive a zoning change under certain circumstances. Based on the lot size of the project in question and the proposed zoning classification, is this project subject to the Affordable Requirements Ordinance? (See Fact Sheet for more information)

YES NO X


Yaroslav Kot _being first duly swom on oath, states that all of the above statements and the statements contained in the documents submitted herewith are true and correct.


Subscribed and Swom to before me this

13" _dav of April 2015

Notary Public

BLUEHRSEN OFFICIAL SEAL |

Notary Public, State of Illinois My Co-RTmlsslon Expires

January 29, 2(n7

For Office Use Only


File Number:

Ward:


AND AFFIDAVIT

SECTION I . - GENERAL INFORMATION


VGS Holdings, L L C


Indicate whether the Disclosing Party submitting this EDS is: 1. [X] the Applicant


Applicant in which the Disclosing Party holds an interest: . OR


B. Business address of the Disclosing Party: 2100 West Erie Street

Chicago, I L 60612

C. Telephone: 847-401-5786 Fax: Email:

D. Name of contact person: Yaroslav Kot



Rezoning for 3530 North Lincoln Avenue

G. Which City agency or department is requesting this EDS? Planning + Development



Ver. 01-01-12 Page 1 of 13

SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS



Person [X] Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)


Illinois


[ ] Yes [ ] No [ ] N/A




Name Title Yaroslav Kot

Vadim Davidiouk


Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. I f none, state "None." NOTE: Pursuant to Secfion 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.


Vadim Davidiouk 2100 W. Erie St., Chicago, I L 60612 50%

Yaroslav Kot 2100 W. Erie St., Chicago, I L 60612 50%

SECTION III ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D OFFICIALS


[ ] Yes [X] No






Page 3 of 13



John Fritchey 758 N. Larrabee, Suite 824, Chicago, I L Attorney $5000 (estimated)









[ ] Yes [ ] No



Page 4 of 13










Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local govemment, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Enfity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13










None

Page 6 of 13



None


None



[ ] is [X] is not





Page 7 of 13





[ ] Yes [X] No

NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D. l . , proceed to Part E.



[ ] Yes [X] No






Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in connection with the Matter voidable'by the City.



SECTION VI ~ CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS

NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section VII . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.





Page 9 of 13







[ ]Yes [ ] N o



[ ] Yes [ ] No


[ ]Yes [ ] N o


[ ] Yes [ ] No


Page 10 of 13






C. I f the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the confract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claiins which it may have against the City in connection with the public release of informafion contained in this EDS and also authorizes the City to verify the accuracy of any informafion submitted in this EDS.



Page 11 of 13



F.3 , I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.




VGS Holdings, LLC (Print or type name of Disclosing Party)

By: (Sign here)

Yaroslav Kot (Print or type name of person signing)


Signed and sworn to before me on (date)

at Cook. nCounty, Illinois (state). C ^ ^ f e ^ ^ ''"^AL SE AL 1 ? Notar? PuilTc. State of Illinois

' < V : ^ ^ N 1 My Comfnission Expires

Notary Public. y ^ ^ ^ ^ 29.2^7

Commission expires:

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND

AFFIDAVIT APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aimt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ovraership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes [X ] No

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is cormected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B




[ ] Yes No


[ ] Yes [ ] No ^ Not Applicable



chicityclerk.s3.amazonaws.comchicityclerk.s3.amazonaws.com/s3fs-public/document_uploads/coun… ·...

Documents

Transcript of chicityclerk.s3.amazonaws.comchicityclerk.s3.amazonaws.com/s3fs-public/document_uploads/coun… ·...