3751 Motor Avenue #341248 - Palms Neighborhood Council

Neighborhood Council Funding Program
APPLIGATION for Neighborhood Purposes Grant (NPG)
FMPOWER
rl
ffi
This form is to be completed by the applicant seeking the Neighborhood Purposes Grant and submitted to the Neighborhood
Council from whom the grant is being sought. All applications for grants must be reviewed and approved in a public
meeting.The Neighborhood Council, upon approval of the application, shall submit the approved application along with all
required documentation to the Department of Neighborhood Empowerment.
Name of Neighborhood Council you are seeking the grant from:
Council Name
Motor Avenue Foundation
45-4505527
1Al Organization Name
Federal l.D. # (Elt{#)
CA
09t2012
State of Incorporation
Date
of 501(c)(3)
Status (if applicable)
1B)
1c)
1D)
3751 Motor Avenue #341248
Los Angeles
Organization Mailing Address
City
Busrness Address (lf different)
City
Sfafe
Zip Code
City
Sfafe
Zip Code
Address of Affiliated Organization (lf
applicable)
Name and address of person designated to receive official/legal notices:
CA
90034
Zip Code
Name:
2l
Sfreef
City
Sfafe
Zip Code
3)
Type of organization- Please select one: (Organizations must be located within the City of Los
i tr puOtic School hot to inctude private schoots)
or itr r 501 (cX3) Non-profits (other than religious institutions)
Attach Letterhead
Attach IRS Determination Letter
4)
Please describe the Neighborhood lmprovement Project for which the grant is intended.
Angeles)
This grant is to help assist with the continuation of the Motor Avenue Urban Garden and Farmers
Market Program by securing materials and construction of the Palms Elementary and Palms Middle
School edible gardens.
5)
How will this grant be used to primarily support or serve a non-discriminatory, public purpose and benefit the
public at-large.
The Motor Avenue Farmers Market has developed an urban garden program to promote the health,
synergy, and self-reliance of its local community. Benefits of these urban gardens include: equitable
food quality and nutrition, community health and sustainability, opportunities for recreation, exercise,
therapy and education, heightened social interaction, crime reduction, preservation of green space,
enhanced quality of life, community development and beautification, and resource efficiency and
independence. This grant is essential to continuing and growing this program and the benefits
associated with it.
City of Los Angeles, Department of Neighborhood Empowerment
NPG APPLICATION Paqe 2
6A)
Requested of
NC
,
5,000
l-otal Proiected Gost
$
s8,s45.oo
D
D
68)
Requested of NC
Construction materials of Palms Elementary and Palms Middle School ( lumber, soil, plants, decomposed granite)
Total Projected Cost
5,000
$
28,733.b1
$
D
o
7l ls the implementation of this specific program or purpose described in box 4 above contingent on any other
factors or sources or funding? 'D Yes, please describe below U trto
Source of Fundinq
Amouni
County of Los Angeles
ti
70.000
l\4otor Avenue lmprovement Associatton
R
20,000
E
10,00
JMB Enterprises, lNC.
fotal Proiected Gost
$
8)
What is the TOTAL amount of the grant funding requested with this application:
e)
What is the expected completion
date? 04 t 01 t 2015 (mmidd/yyyy)
$
10,000
(required)
Provide the name, telephone number, fax and e-mail address (if applicable) of the person(s) responsible for
the funds and proqram(s) listed in Section ll of this application.
Lee
Wallach
10A) Frrsf Name
(310)202-e002
Telephone Number
Last Name
(310)202-0433
Fax Number
Polizzotto
10Bl First Name
Last Name
(310)202-9002
[email protected]
E-mail
Nikki
Telephone Number
MI
MI
(310)202-0433
Fax Number
member? [
the Office of the City Attorney? fl Yes il No
11) ls there a former or existing relationship between your organization and a NC board
11A) lf yes, did you and/or the board member consult
fvoe of Relationship
Board Member Name
Example: Former board member
So Conflicted
Yes
gNo
City of Los Angeles, Department of Neighborhood Empowerment
NPG APPLICATION Paoe 3
I hereby affirm that, to the best of my knowledge, the information provided herein and communicated otherwise is
truly and accurately stated. I further affirm that I have read Appendix A, "What is a Public Benefit," and Appendix B
"Conflicts of lnterest" of this application and affirm that the proposed project(s) and/or program(s) fall within the
criteria of a public benefit project/program and that no conflict of interest exist that would prevent the awarding of
Two signatures required
12A) Executive Director of Non-Profit Corporation or School Principal
Lee Wallach
Executive
PRINT First Name/ Last Name
Title
Director
"1,.*,;,r
Signature
j,/' t" ,.-/
-i-gt/ly'
Date I
12B) Secretary of Non-profit Gorporation or Assistant School Principal
Nikki Polizzotto
Project Manager
i.
PRINT First Name/ Last Name
Title
Date
iReviewer Name
'i
,
rjj
Date Reviewed
I
lneverweR's NorES
I
lDate submitted to Funding lJnit
Funding Unit Notes:
P-9NE-Pslp--s-{ernp-E-eg-ef-t------------------i
-j
Palms Middle School Budget
Materials
Item Name:
Unit Price:
Quantitv:
Total Price:
Raised Garden Bed Material
Planter Box Mix Soil
Landscape Fabric
60
528.00
51,680.00
4
546.89
s187.s6
145
st3.12
s1,902.40
30
57.74
5232.20
5
s2s.00
s30.00
s12s.00
7
Recycled Pallets
4
51s.00
577.00
560.00
Screws 1lb box
2
58.s0
517.00
Decomposed Granite
Decomposed Granite with Stabilizer
1.
s2,100.00
52,100.00
Delivery Fee
1
Ssoo.oo
ss00.o0
10
s14.99
s149.90
3
s10s.00
1008
53s.00
s8.00
s1.00
so.7s
10
$gs.oo
53s0.00
2XIOX12 Doug Fir W.ood
4X4X8 Douglas Fir S4S Lumber
Wood Sealant (5 eal)
Deck Mate Screws (5lbs per box)
Compcist Bin
s210.00
Grip-Rite 8X3 Coarse polyumer coated steel
Trees and Plants
Native Plants (1 gallon)
Fruit Trees (15 gallon)
for Fruit Trees
Kellog Ammend Soil
3
s00
Seeds
Seedlings
Native Plants (5 gallon)
lrrieation Supplies
Va lves/Pa rts/Fitti ngs
s1,600.0c
So.+s
S57.sc
s3S4.oo
s1,000.00
Bench Seatine
Cambridge 4' Flat Bench
2
s1e2.oo
Polly Tuff Easy Access 6' Picnic Table
1.
S1,ooo.oo
Tools
Wheelbarrows
s7s6.00
s800.00
150
2,500 PVC Line
524.00
Ssoo.oo
s1,630.00
1.
Cages, Stakes, Trellising Materials
Miscellaneous Tools
Shears
1.
Shovels
2
Butcher Block Table
1.
Greenhouse
L
Wine Barrel Planters
Misc cooking tools
4
I
s1so.00
s200.00
s2oo.oo
sso.00
s40.00
s380.00
s4s0.00
s4o.oo
Sgso
s1s0.00
5200.00
5200.00
sso.oo
s4o.oo
Sgso
Paint (gallons)
Varnish (gallons)
s3s.00
s100.00
s100.00
s7s.00
Paint Brushes and Rollers
LA City Mural Registration Fee
s3s0.00
s300.00
s100.00
s7s.00
Materials Grand Total
Labor. Allocations
Hours
Corpsmembers (5) per day
Technical Oversight
Landscape Planning
Artist Compensation (3) per day
Program Director
Coordinator
Additional Labor (DG and lrrigation)
Additional Labor (Excavation)
Additional Labor (Backfill)
Labor Rate:
Tota Labor Cost:
330
s27.OO
40
Soo.oo
s2,400.00
40
58s.oo
120
S3o.oo
s3,4oo.oo
S3,6oo.oo
L25
530.00
53,750.00
75
s40.00
s27.00
s3,000.00
258
100
527.O0
95
$27.00
Labor Grand Total
Added Cost
Hours:
Unit Price:
Added Cost Grand Total
Grand'Total:
537,295.00
Total Price:
$o.oo
551,700.56
s27,508.56
517,692.00
544,7O0.56
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PALMS ELEMENTARY SCHOOL
Materials
Item Name:
Iotal Price:
Unit Price:
Quantity:
575s.78
Raised Garden Bed Material
24
Planter Box Mix Soil
528.00
s46.89
2
Landscape Fabric
5672.00
$gs.zs
s77.00
Compost Bin
Recycled Pallets
4
s1s.00
560.00
Screws Llb box
Grip-Rite 8X3 Coarse polyumer coated steel
2
s8.s0
Srz.oo
s246.00
Outdoor Sink and Work Table
Mustee E. L.& Sons lnc L8in X 34 In Plastic Laund
2X4Xl2 Douglas Fir Boards
3/4 Plywood
Soil Delivery Charge
Shaded Area
t
6
1
1
588.00
s4.oo
s34.00
s100.00
s88.oo
s24.00
s34.oo
Sloo.oo
52,888.07
t
Shade Sail System
Outdoor Shed
3utdoor Storage Building 4X6
I
s400.00
s400.00
54,200.00
Decomposed Granite
Decomposed Granite with Stabilizer
Delivery Fee
t
1
s3,700.00
ss00.00
s3,700.00
ssoo.00
Trees and Plants
Native Plants (1 gallon)
Fruit Trees (15 gallon)
5
S14.9s
L
574.9s
s3s.oo
3
s3s.00
s8.oo
53s.oo
s800.00
516.00
150
50.4s
Kellog Ammend Soil for Fruit Trees
Native Plants (5 gallon)
t
5
lrrigation Supplies
Hose Bibs
Va lves/Pa
S64.oo
51,600.00
rts/Dri p/Fitti ngs
2,500 PVC Line
Copper Pipe
58.00
517s.00
s2,061.00
S67.so
S33o.oo
S162.1s
Bench Seating
572.7s
1X6X8 Douglas FirlHem Board
1.5
2X4X8 Premium Kiln Dried Whitewood Stud
Deck Mate Screws (5lbs Per Box)
12
s4.8s
52.4s
$2e,40
2
S3o.oo
560.00
Wheelbarrows
2
1
51s0.00
s20o.o0
5200.00
ss0.00
s40.0o
S3oo.oo
Cages, Stakes, Trellising Materials
Miscellaneous Tools
Tools
t
Shears
1
Shovels
4
S2oo.oo
s20o.oo
Sso.oo
s160.0o
PALMS ELEMENTARY SCHOOL
wine barrel planters
15
ss0
STso
Butcher block table
Indiction burners
5300
2
5300
5100
Misc cookine tools
1.
S3so
10
s35.oo
3
Sloo.oo
s3s0
s82s.00
53s0.00
s300.00
1)
5100.00
Sloo.oo
1)
s7s.00
Szs.oo
MuralMaterials
Paint (gallons)
Varnish (gallons)
Paint Brushes and Rollers
LA City Mural Registration Fee
Materials Grand Total
Labor Allocations
Corpsmembers (5) per day
Labor Rate:
Hours
5100
5'J.4,327.95
Tota Labor Cost:
300
527.OO
S8,i.oo.oo
Technical Oversight
40
40
s6o.oo
s8s.oo
s2,400.00
Landscape Planning
S3o.oo
s3,600.00
530.00
540.00
S3,75o.oo
Artist Compensation (3) per day
Program Director
Coordinator
120
125
Labor Grand Total
Added Cost
Scissor Lift (per day)
3
Iotal Price:
s200.00
Added Cost Grand Total
Grand
lmmediate ln-Kind Contributions
mmediate Budgetary Needs
Future Garden Enhancements
I
lmmediate Budeetarv Needs
Total Materials Cost
Total Labor Cost
Total Garden Budget
lcost:
I 511,900.00
I
58,100.00
Total:
So.oo
s21,250.00
Unit Price:
Quantity:
53,400.00
s600.00
Sooo.oo
536,177.95
($)
Pa
ruM.MflMBeffiM$ &rdem
lrws ta [d d le,-Sch ool
NN
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W
1e
The gorden ot Polms Middle School is not
currently being utilized. We will help restort the
gorden progrom by increosing stoff
involvement ond clossroom integrotion for
students. There ore l4 gorden boxes olreody
in ploce. The gorden will be equipped with o
DG Poth, shoded teoching oreo, odditionol
seoting, o secure storoge shed, designoted
compost oreo ond exponded drip irrigotion.
I
IIilIERNAL RFVENUE
P. O.
CINCINNATI,
oare,
SERVTCA
DgfAhrwGNf' ritrlr.it*l'msiassny
BOX 2s08
OIt
45207-
gfp 27
78t12
nmployer fdentif ication Nrunber :
45-5405527
DI,N:
.. . ,
.:li.
L70;l$ffi53 77'692
MOTOR A\I.ENUE
rouuoanroN
37s1 MOiOR A\rE gTE 341248
IJOS ANGELES,
CA
90034
contti6t personi
GERRY R MCLAUGIUJIN
ID#
Contact Telephorle Nurnber:
(8zz)'329-5t6
Aacourlglng period Ending:
3111.s
Decentber 3l
public Charity Status:
1?o ibt (1iTAi'(vii
Forn 990 Required:
Yes
Effectlve Date of
March L2, ZO:-,z
E5cemption:
ContrLbution Deductib{1 ity
:
Ye€r
Addendum AppLies:
No
Dear Applicant,;
we are pleased to inform you ttrat upon review of your appticatibn for tax
exempt statua lte lrave determl-ned that you are exenpt from pederal income cax
under section 501(c) (3) ot the rnternal Rev$rue code. contrtbutiona to yoll are
deductlble under secLion 1?0 of the Code. You are aloo qualified to
".e*irre
tax deductible bequesta, devi€e6. transfer€r or gifca under section 2055,
21,08
ot 2522 of the Code. Becauee this let,ter coul"d heJ.p reeoJ.ve.rny quest,Lon6
regarding your exempt status, you ehould keep it, 1n your perman€nE recorids.
organizationg exempt under sectiod 501(c) (3) or the cod.e are furiher cLassified
ae either pr.rbllc charLtie'b or private foundatione. we dduetind.ned that, you are
a Publie charity ril:ldsr the code 6e@,tiion(s) 1{eAe"d tn trner.{piStBng,@,6 ,,t&&s
f€gter..
P]ease see encLoged publication 4a2t-pc, conpltance cuide for s01(c) (3) Fulrlic
charitiea, for some hetpful information about your reaponeibilit,j.ee aa an
exempt organlzatlon.
Letter
947
(DO/CG)
ry
MOTOR AVENUE FOIINDATIOT,I
srncerely,
{1,(!,o lr^
irorlyY. uaz A
Director, nxempt Organj-zations
Rulings and Agreemenbs
Encl0sure:
publicatioil
4221-pC
Let Ler
94?
(DO,/CG)
Form
w-9
Request for Taxpayer
ldentification Number and Certification
(Rev. P ugust 201 3)
-freasury
Departr nent of the
Intemal Revenue Service
Give Form to the
requester, Do not
send to the lRS.
Name (as shown on your incomo tax return)
Motor Avenue Foundation
N
o Motor Avenue
I
Association
Exemptions {see instructions):
Check appropriate box-for federal tax classification:
I
^,Y
i.b
E-s
eo
'6
o
6
o
lndividual/sole
proodeior E]
C
Coriroration
n
S
Corporation
I
Partnership
I
TrusVestate
Exempt payee code (if
!
Limiteo liability company. Enter the tax clas$ification (c=c corporation, s=s corporation, P=pannership)
!
Other lsee instructions)
>
any)_
Exemption from FATCA reporting
code (if any)
>
Address (number, street, anal apt- or suita no.)
Rsquester's name and address (optional)
3751 Motor Ave #341248
City, state, and ZIP cods
a{) Los Anoeles.
CA 90034
List account number(s) here (optional)
Ta
your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line
Enter your
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3, For other
entities, it is your employer identification number (ElN). lf you do not have a number, see How lo get a
I/N on page 3.
Social aecurity number
[Ln m
nrl
Note. ll the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2.
I am not subject to backup withholding because: (a) | am exempt from backup withholding, or (b) | have noi been noti{ied by the Internal Revenue
Service (lRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IBS has notified me that I am
no longer subject to backup withholding, and
3.
I am a U.S. citizen or
other U.S. person (defined below), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA repofting is correct^
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all inierest and dividends on your tax return. For real estate transactions, item 2 does not apply. For moftgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangemont (lRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TlN. See the
instructions on page 3.
Sign
Here
s,ignatureor-
U.S.person)
..--- _.-,.1t
-t#
"rr/
/L-/Jr/
- Dste>
General Instrubiions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developmenls. The IRS has created a page on lRS.gov for information
about Form W-9, atwww.irs.govlwg. Information about any luture developments
affecting Form W-9 (such as legislation enacted after we release it) will be posted
on that page.
tt
"'/ '/=:
-
z Jt*1
withholding tax on foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct.
Note. lf you are a U.S. person and a requestgr gives you a form other lhan Form
W-9 to request your TlN, you must use the requester's form it it is substantially
similar to this Form W-9.
Definition of d U,S, person. For lederal tax purposes, you are considered a U.S.
Purpose of Form
person if you aro:
A person who is required to file an inrormation return with the IRS must obtain your
correct taxpayer identification number (flN) to report, for example, income paid to
you, payments made to you in settlement of payment card and third party network
transactions, real estate transaclions, mortgage interest you paid, acquisition or
abandonment of secured propedy, cancellation of debt, or contributions you made
to an lRA.
A partnership, corporalion, company, or association created qr organized in the
United Statos or underthe laws of the United States.
. An estate {other than a loreign estate), or
. A domestic trust (as definod in Regulations section 301 .7701 -7)-
Use Form W-9 only if you are a U.S. person (including a resident alien), to
provide your correct TIN to the person requesting it (the.equestef) and, when
applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup wilhholding if you are a U.S. exempt Payee. lf
applicable, you are also certifying that as a U.S" person, your ailocable share of
any partnership income from a U.S. trade or business is not subject to the
.
.
An individual who is a U.S. citizen or U.S. resident alien,
Special rules tor partnerships, Partnerships that conduci a trade or business in
the United States ars generally required to pay a withholding tax under section
1 446 on any foreign partners' share of elfoctively connected taxable income from
such business, Further, in cartain cases where a Form W-9 has not been recaived,
the rules under section 1 446 require a partnership to presume that a partner is a
foreign person, and pay the section 1 446 withholding tax- Theretoro, ii you are a
U.S. person that is a partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1 446 withholding on your share of partnsrship income.
Cat. No. 10231X
Form
W-9
{Rev. 8-2013)