COOK COUNTY ASSESSOR’S OFFICE 118 NORTH CLARK STREET, CHICAGO, IL 60602 PHONE: 312.443.7550 FAX: 312.603.3352 WWW .COOKCOUNTYASSESSOR.COM COOK COUNTY ASSESSOR JOSEPH BERRIOS CLASS C ELIGIBILITY APPLICATION This application, along with the supporting documentation and a certified copy of an adopted ordinance, both described below, must be filed with the Cook County Assessor’s Office within one year of receipt of a “No Further Remediation Letter” from the Illinois Environmental Protection Agency’s Site Remediation Program. Applicant Information Name: _____________________________ Telephone: (_____)_______________________ Federal Employer Identification Number: __________________________________________ Address: ___________________________________________________________________ City: ______________________ State: __________ Zip Code: ______________________ Contact Person (if different than the Applicant) Name: _____________________________________________________________________ Company: __________________________ Telephone: (_____)_______________________ Address: ___________________________________________________________________ City: ______________________ State: __________ Zip Code: ______________________ *Note: If title to the property is held or will be held in trust or by a corporation or a partnership, attach additional pages with the names, addresses and telephone numbers of all of the trust beneficiaries, corporate officers and/or general partners. Description of Subject Property (per PIN) Place a check beside those receiving remediation. If you are applying for more than three different PINs, please submit the additional PIN in an attachment. 1 of 4 12/28/2010 American LegalNet, Inc. www.FormsWorkFlow.com Property Description (per PIN) If you are applying for more than three different PINs, please submit the additional PIN information in an attachment. Street address: (1) _________________________________________________________ Permanent Real Estate Index Number: ____________________________ (2) _________________________________________________________ Permanent Real Estate Index Number: ____________________________ (3) _________________________________________________________ Permanent Real Estate Index Number: ____________________________ City: ______________________ State: __________ Zip Code: ______________________ Township: _______________________ Existing Class: __________________________ (Please Circle) Industrial / Commercial Split Codes: _______________________ Attach remediation site base map with sufficient details and accuracy to show all of the following: A. A distance of at least 1,000 feet around the remediation site at a scale no smaller than one inch equal to 200 feet; B. Map scale, north arrow orientation, date, and location of the remediation site with respect to township, range and section; C. Approximate boundary lines of the remediation site, with the owners of adjacent properties clearly indicated, if reasonably identifiable; D. Surrounding land uses (e.g., residential property, industrial, commercial property, agricultural property, and conservation property). Identification of Persons or Entities Having an Interest Attach a complete list of all owners, developers, occupants and other interested parties (including all beneficial owners of a land trust) identified by names and addresses, and the nature and extent of their interest. Date of purchase: ________________________________________________ Name of purchaser: _______________________________________________ Name of seller: __________________________________________________ Relationship of purchaser to seller:_____________________________________ The present owner(s) must successfully demonstrate that they were not responsible, directly or indirectly, for the contamination that was remediated pursuant to a Site Remediation Program. 2 of 4 12/28/2010 American LegalNet, Inc. www.FormsWorkFlow.com Property Use 1. Identify the current and post-remediation uses of the remediation site, attaching a detailed description of the precise nature and extent of the intended use of the subject property, specifying in the case of multiple uses the relative percentages of each use. Include copies of materials which explain each occupant's business, including corporate letterhead, brochures, advertising material, leases, photographs, etc. 2. Submit a complete copy of the “No Further Remediation Letter” and attachments as received from the Illinois Environmental Protection Agency (IEPA). 3. Submit by affidavit itemized remediation costs, noting all costs incurred at the IEPA, all remediation and removal costs, all monitoring and engineering costs, and all legal fees. Nature of Development Indicate nature of the development by checking the appropriate space: [ ] New Construction [ ] Substantial Rehabilitation [ ] Operating Establishment (at the time of filing this Application, along with the supporting documentation and ordinance, an “Incentive Appeal Form” for reclassification must also be filed) [ ] Abandoned Property If the proposed development consists of new construction or substantial rehabilitation, provide the following information: Estimated date of construction commencement (excluding demolition, if any): ________________________________ Estimated date of construction completion: ___________________________________ Attach copies of the following: 1. specific description of the proposed new construction or substantial rehabilitation 2. current plat of survey for subject property st 3. 1 floor plan or schematic drawings 4. building permits, wrecking permits and occupancy permits (including date of issuance) 5. complete description of the cost and extent of substantial rehabilitation or new construction, absent remediation costs, (including such items as contracts, itemized statements of all direct and indirect costs, contractor's affidavits, etc.) The owner has one year from the application date filing to commence construction. When construction is complete or when re-occupancy occurs, the owner must file an “Incentive Appeal Form” for reclassification. 3 of 4 12/28/2010 American LegalNet, Inc. www.FormsWorkFlow.com Employment Opportunities How many construction jobs will be created as a result of this development? __________ How many permanent full-time and part-time employees do you now employ in Cook County? Full-time: __________ Part-time: _________ How many new permanent full-time jobs will be created as a result of this proposed development? _________ How many new permanent part-time jobs will be created as a result of this proposed development? _________ Local Approval A certified copy of a resolution or ordinance from the municipality in which the real estate is located (or the County Board, if the real estate is located in an unincorporated area) must accompany this application. The ordinance or resolution must expressly state that the municipality supports and consents to this Class C Application. I, the undersigned, certify that I have read this Application and that the statements set forth in this Application and in the attachments hereto are true and correct, except as those matters stated to be on information and belief and as to such matters the undersigned certifies that he/she believes the same to be true. ___________________________________ Signature of Owners* ________________________ Date ___________________________________ Title *If title to the property is held in trust or by a corporation or a partnership, this Class C Eligibility Application must be signed by the beneficiary, officer or general partner. FOR ASSISTANCE IN PREPARING THIS APPLICATION, PLEASE CONTACT THE ASSESSOR’S OFFICE, SPECIFIC PROPERTIES DEPARTMENT AT (312) 603-7529. 4 of 4 12/28/2010 American LegalNet, Inc. www.FormsWorkFlow.com