MEMORANDUM FOR TRAFFIC REGULATIONS
OVERRIDE
PROHIBITION AGAINST PARKING (Except for the Handicapped):
Street, etc:
East 83rd Place
Location, etc:
No. 1637
(Permit No. 77471)
Distance or extent:
Hours:
at all times
Days:
no exceptions
CARLEAN WOODS
MICHELLE A. HARRIS Alderman, 8th Ward
01/05/2011 WED 15:08 FAX
21003/00
4
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
77471
An application will not be considered complete unless:
• All lines of the application have been completed in full;
• A check or money order tor S70.00 made payable to the City ol Chicago is submitted as payment ol the applicalion fee; Please note: The application fee shall be waived for any person holding a valid, current disabled veterans piale
• 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 ot your drivers license, slate 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).
1. Date of Birth
MO _ D*r
&S1
4. Applicant Last Name
2 State Identification Number
i i
1
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3 Drivers License Number
Ml J First Name-
5. Home Address (primary residence)
STREET NUMBER | HIM ISTHttT NAME /
6. Address where signs will be posted
STREET NUMBER 1 illH.
STHEtT NUMBER 1 iHH. I__JIH££T HW):
7. Phone Numbers 1 ft
Home
in
8. Current Permanent Disabled Placard Number
9. Current License Plate Number
JL±.±
Business
i_Ll.....
J________J_
* Registefed lo i nciatiuu^nip tu
CArfavj covo^ \......Se/.r-
Relationship to Applicant
Registered to
City Sticker No.
Relationship to Applicant
10. Description of Medical Condition arid Disability
Alternative Parking: Please note your application may be denied if you have alternative accessible orf:street parking options
tl.ls there off-street parking available at your primary residence (i.e., garage, car port, driveway, etc.)?___
res j no
iS.l^you answered Ves to question 11. please describe: (□'Garage: J Driveway: J Car Port: J Oiher.
13. re your oll-slreet parking accessible? ^ Yes: □ No Please explain:
14. Allirmation. I hereby a11irm that the above inlormation is true ond correct. H lhe Clvy of Chicago Department of Revenue determines that lhe applicant has lalsely represented one or more of the above conditions, ihe applicant shall be subject to a fino of 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 ot Revenue of any changes m ihe information provided.
Signature L-.C^^k. ^ _
Date
Chech
J COMPLETE #7/'V>:-
FOR OFFICE USE ONLY
PLACARD/PLATE
ESIDENCY
01/.05/2011 WED 15:09 FAX