i^^^ APPLICATION FOR DISABLED PARKING SIGNS 71057
l|fi PLEASE READ THE FOLLOWING CAREFULLY
^HBr BEFORE COMPLETING THE FORM
An application will not be considered complete unless: « All lines of the application have been completed in lull;
• A check or money order for $70.00 made payable to the City of Chicago is submitted as payment of the application fee; Please note: The application fee shall be waived for any person holding a valid, current disabled veterans plate.
• Disability must be permanent as evidenced by a copy of your valid disabled placard and/or current vehicle registration submitted at the time of application;
Proof of residency, in the form of a copy of your drivers license, state identification, or utility bills are submitted at the time of application.
Completed application forms may be returned to: the office of your alderman, any City of Chicago Department of Revenue facility, or via mail at P.O. Box 803100, Chicago, IL 60680-3100. ATTN: Disabled Permitting Section. A $25.00 maintenance fee will be billed to you annually. Should you have questions or concerns, please call our permit processing division at 312-744-PARK (7275).
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4. Applicant Last Name |
Ml First Name |
5. Home Addres9 (primary |
"residence) |
6. Address where signs w STREET NUMBER I 0IR OI4IM\H 1 Is |
II be posted 1 ' STREET NAME uilhU\o\c 1 / lei 1 |
. WAnt) NUMBER 1 1 1 1 1 1 1 1 1 1 1 1 1 1 |
7. Phone Numbers Home n i n 13 T 41 2 i 12. |
ic r? |
Business I l T l I T I 1 1 |
8. Current Permanent Disabled Placard Number ft A |
Registered to |
Relationship to Applicant |
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9. Current License Plate Number |
Registered to |
City Sticker No. books') |
Relationship to Applicant |
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10. Description ol Medical Condition and Disability |
Alternative Parking: Please note your application may be denied il you have alternative accessible off-street parking options. |
11. Is therBDtt«street parking available at your primary residence ^YES □ NO (i.e parage) car port, driveway, etc.)? f |
12.lf#ou answered Yes to question 11, please describe: Q&1L*<\ <. ^ A tf'«c H* e<y r>-flr «c <» i 11» l«- B<j Stefx, ^Garage; □ Driveway; □ Car Port: □ Other: UiVutln ,j Hftfd to Cl.flilo- <jfliuwj€. duuf >S Hforl Tc p» (I UpO |
13.19 your otf-streotxiarking accessible? □ Yes: ^0 No. Please explain: |
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14. Affirmation; I hereby affirm that the above information is true and correct. If the City of Chicago Department of Revenue determines that the applicant has falsely represented one or more of the above conditions, the applicant shall be subject to a fine ol not less than $100 but no more than $500, and the application shall be denied. I also understand that it is my responsibility to notify the Department of Revenue of any changes in the information provided.
Date . 3J4aJ lOlO
Signature
MEMORANDUM FOR TRAFFIC REGULATIONS
OVERRIDE
PROHIBITION AGAINST PARKING (Except for the Handicapped):
Street, etc:
South Whipple Street
Location, etc:
No. 7944
(Permit No. 71057)
Distance or extent:
Hours:
at all times
Days:
no exceptions
KATIE LINDSEY
LOfJA LANE Alderman, 18th Ward