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Application 1/2/2018 ig-oci OR IC! ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD APPLICATION FOR PERMIT- 02/2017 Edition ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD APPLICATION FOR PERMIT SECTION I. IDENTIFICATION, GENERAL INFORMATION, AND CERTIFICATION This Section must be completed for all projects. Facility/Project Identification Facility Name: Garfield Kidney Center Street Address: 408 — 418 North Homan Avenue City and Zip Code: Chicago, Illinois 60624 County: Cook Health Service Area: 6 Health Planning Area: 6 licant (refer to Part 1130.220 Exact Legal Name: DaVita Inc. Street Address: 2000 16m Street City and Zip Code: Denver, CO 80202 Name of Registered Agent: Illinois Corporation Service Company _f_tegistered Agent Street Address: 801 Adlai Stevenson Drive Registered Agent City and Zip Code: Springfield, Illinois 62703 Name of Chief Executive Officer: Kent Thiry CEO Street Address: 2000 16m Street CEO City and Zip Code: Denver, CO 80202 CEO Telephone Number: 303-405-2100 _Type of Ownership of Applicants • Non-profit Corporation • Partnership • For-profit Corporation O Governmental ▪ Limited Liability Company o Sole Proprietorship P Other o Corporations and limited liability companies must provide an Illinois certificate of good standing. o Partnerships must provide the name of the state in which they are organized and the name and address of each partner specifying whether each is a general or limited partner. APPEND DOCUMENTATION AS ATTACHMENT 1 IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPLICATION FORM. ontact IPerson to receive ALL correspondence or in uiries Name: Tim Tincknell Title: Administrator Company Name: DaVita Inc. Address: 2484 North Elston Avenue, Chicago, Illinois 60647 Telephone Number: 773-278-4403 E-mail Address: [email protected] Fax Number: 866-586-3214 Additional Contact Person who is also authorized to discuss the application for permit Name: Brent Habitz Title: Regional Operations Director Company Name: DaVita Inc. Address: 1600 West 13th Street, Suite 3, Chicago, Illinois 60608 Telephone Number: 312-243-9286 E-mail Address brenthabitdavita com Fax Number: 855-237-5324 ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD APPLICATION FOR PERMIT- 02/2017 Edition ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD APPLICATION FOR PERMIT SECTION I. IDENTIFICATION, GENERAL INFORMATION, AND CERTIFICATION This Section must be completed for all projects. FacilitvlProiect Identification Facility Name: Garfield Kidney Center Street Address: 408 — 418 North Homan Avenue City and Zip Code: Chicago, Illinois 60624 County: Cook Health Service Area: 6 Health Planning Area: 6 A licant s Provide for each applicant refer to Part 1130.220 I Exact Legal Name: Total Renal Care Inc. Street Adritilir —2-0-016b Street City and Zip Code: Denver, CO 80202 Name of Registered Agent: Illinois Corporation Service Company Registered Agent Street Address. 801 Adlai Stevenson Drive Registered Agent City and Zip Code: Springfield, Illinois 62703 Name of Chief Executive Officer: Kent Thiry CEO Street Address 2000 16'n Street CEO City and Zip Code: Denver, CO 80202 CEO Telephone Number: 303-405-2100 ype of Ownership of Applicants 0 Non-profit Corporation o Partnership • For-profit Corporation • Governmental O Limited Liability Company o Sole Proprietorship 0 Other o Corporations and limited liability companies must provide an Illinois certificate of good standing. o Partnerships must provide the name of the state in which they are organized and the name and address of each partner specifying whether each is a general or limited partner. APPEND DOCUMENTATION AS ATTACHMENT I IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPUCATION FORM. Primary Contact Person to receive ALL correspondence or inquiries Name: Tim Tincknell Title: Administrator Company Name: DaVita, Inc. Address: 2484 North Elston Avenue, Chicago, Illinois 60647 Telephone Number: 773-278-4403 E-mail Address: [email protected] Fax Number: 866-586-3214 Additional Contact Person who is also authorized to discuss the.application for permit Name: Brent Habitz Title: Regional Operations Director Company Name: DaVita Inc. Address: 1600 West 13In Street, Suite 3, Chicago, Illinois 60608 Telephone Number: 312-243-9286 E-mail Address: [email protected] Fax Number: 855-237-5324 61455952.2 ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD APPLICATION FOR PERMIT- 02/2017 Edition Post Permit Contact [Person to receive all correspondence subsequent to permit issuance-THIS PERSON MUST BE FMPLOYED BY THE LICENSED HEALTH E FACILITY AS DEFINED AT 20 ILCS 3960 Name: Kara Friedman Title: Attorney Company Name: Polsinelli PC Address: 150 North Riverside Plaza, Suite 3000, Chicago, Illinois 60606 Telephone Number: 312-873-3639 E-mail Address: [email protected] Fax Number: 312-873-3793 Site Ownership Exact Legal Name of Site Owner: Clark Street Real Estate LLC Address of Site Owner: 980 North Michigan Avenue, Suite 1280, Chicago, Illinois 60611 Street Address or Legal Description of the Site: No survey exists yet on the property and therefore the Landlord / Developer cannot provide a legal description at this time. Please see attached Pin Nos: 1611227022 & 1611227023 on the following pages. APPEND DOCUMENTATION AS ATTACHMENT 2 IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPLICATION FORM. Operating Identity/Licensee IPrnvidp this"information for each aoolicable facilityn insert after this page Exact Legal Name: Total Renal Care Inc. Address 2000 16m Street, Denver, CO 80202 0 Non-profit Corporation • Partnership El For-profit Corporation El Governmental • Limited Liability Company • Sole Proprietorship 0 Other o Corporations and limited liability companies must provide an Illinois Certificate of Good Standing. o Partnerships must provide the name of the state in which organized and the name and address of each partner specifying whether each is a general or limited partner. o Persons with 5 percent or greater interest in the licensee must be identified with the % of ownership. APPEND DOCUMENTATION AS ATTACHMENT 3, IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPLICATION FORM. Organizational Relationships Provide (for each applicant) an organizational chart containing the name and relationship of any person or entity who is related (as defined in Part 1130.140). If the related person or entity is participating in the development or funding of the project, describe the interest and the amount and type of any financial contribution. APPEND DOCUMENTATION AS ATTACHMENT 4 IN NUMERIC SEQUENTIAL ORDER AFTER THE LAST PAGE OF THE APPLICATION FORM. 61455952.2 • -- Pag43— Property Details Page 1 of 1 Property Data Exemption History Appeal History Certificate of Error Property Characteristics 2017 Tax Year Property Information PIN: 16-11-227-023-0000 Property Location: 408 N HOMAN AVE City: CHICAGO Township: West Chicago Property Classification: 0 Square Footage (Land): Neighborhood: 101 Taxcode: 77052 16112270230000 11/06/2006 Assessed Valuation 2017 First Pass 2016 Board of Review Certified Land Assessed Value Building Assessed Value Total Assessed Value Property Characteristics Estimated 2017 Market Value Estimated 2016 Market Value Description Age Building Square Footage Assessment Pass First Pass *Property Location" is not a legal/postal mailing address. Its sole purpose is to help our Office locate the property. Therefore, you should not utilize the property location for any purpose, however, you may update the Property Location with your Legal/Postal Mailing Address should you choose to do so. Updating the address will not change the Properly Location to a Legal/Postal Mailing Address, I ** Information may be available by submitting an FOIA Request -4- http://cookeountyassessor. com/Property.aspx?mode=details&pin=16112270230000 9/15/2017 Property Details Page 1 of 1 Property Data Exemption History Appeal History Certificate of Error Property Characteristics 2017 Tax Year Property Information PIN: 16-11-227-022-0000 *Property Location: 418 N HOMAN AVE City: CHICAGO Township: West Chicago Property Classification: 0 Square Footage (Land): Neighborhood: 101 Taxcode: 77052 16112270220000 11/06/2006 Assessed Valuation 2017 First Pass 2016 Board of Review Certified Land Assessed Value Building Assessed Value Total Assessed Value Property Characteristics Estimated 2017 Market Value Estimated 2016 Market Value Description Age Building Square Footage Assessment Pass First Pass • 'Property Location" is not a legal/postal mailing address. Its sole purpose is to help our Office locate the property. Therefore, you should not utilize the property location for any purpose, however, you may update the Property Location with your LegaUPostal Mailing Address should you choose to do so. Updating the address will not change the Property Location to a Legal/Postal Mailing Address. I I " Information may be available by submitting an FOIA Request -5- http://cookcountyassessoncom/Property.aspx?mode=details&pin=16112270220000 9/15/2017 ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD APPLICATION FOR PERMIT- 02/2017 Edition Flood Plain Requirements Refer to application instructions. Provide documentation that the project complies with the requirements of Illinois Executive Order #2006-5 pertaining to construction activities in special flood hazard areas. As part of the flood plain requirements, please provide a map of the proposed project location showing any identified floodplain areas. Floodplain maps can be printed at www.FEMA.qov or
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