CITY OF CHICAGO BACP-PWU BUNDLE PERMIT APPLICATION ■ V.09.28.10 --
APPLICATION TO USE THE PUBLIC RIGHT OF WAY
S&^&SfrSKOf EICEUSE'ONLY,'. ■ WS&f |
006 PERMIT 0: |
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AMNESTY ELIGIBLE? |
□ YES |
□ NO |
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. APPLICANT IN FORMA TION
LEGAL NAME OF ENTITY: f ft V>} o\ vv £ ^ \ A (X \ P Svrtl on Xvu
^ PERMIT MAILING ADDRESS: H<f-(^ A J \A-fd^\-C-
CITY:flun rAfe . STATE: U ZIP CODE: AO 2- S~ CONTACT PERSON: fl >A -g r 7--^- TITLE: gtr c_c ;oJVr m"T PHONE:<gqn_\? FAX:__ E-MAIL:_
FATE fJ HEUA BUILDING OWNER INFORM A TION
NAME: (V\ ftrC k £ #J> A,_
ADDRESS: UJ Ma^MH<.
CITY: CM^ c/> ^ STATE: _ZIP CODE: t %
PHONE: T>3 H<o3- f\3\ FAX: _E-MAIL:_
USE OF THE PUBLIC WA Y
1. List the proposed or existing use below and complete the worksheet on page 3. Hse only one application for all public way use type.
TYPE_ HOW MANY? BUILDING ADDRESS
2. Please enclose one sketch of each proposed use of the public way, which maps to scale the proposed use(s) and its relationship to surrounding right-of-way. All measurements must be indicated.
The prints should also accurately depict the location of the property line and public facilities (meters, light poles, sidewalks).
APPLICANT CERTIFICA TION
I hereby certify that all statements made as part of the application, and the attachments herein, are true to the best of my knowledge and belief.
BY:VFA^^^--"""" _TITLE: T g-S^ eJ-ewT~
F.E.I.N. onSOaAt-OCOURIT-y NUMBER: 3H -\h\Oio9>(o _
ALDERMAN'S APPROVAL
As part of this application process, you are required to notify/obtain approval from the Alderman in whose ward your proposed use of the public way is located.
ALDERMAN'S SIGNATURE: )/ DATE: lo/tfe/amp WARD: 3^>
C H I C a c o
Department of Business Affairs and Consumer Protection (BACP) Business Assistance Center (BAC) Public Way Use Unit (PWU) City Hall, Room 800 121 North LaSalle Street, Chicago, Illinois 60602