APPLICATI3N FOR DIS/ BLED PARKING SIGNS PLEASE HEAD THE FOLLOWING CAREFULLY BEFOR E COMPLE TING THE FORM
73604
An application will not be considered corr )lett: unless:
An lines of the application nave been :orr. oleted in full;
A check or money order for $70.00 m ide oayable to the Oity of Chicago is submitted as payment of the. application fee,
shai be vaived for any persen holding a valid, current disabled veterans plate, evid in«d by a copy of ''O'Ji'valid disabled placard and/or current vehicle registration tion;
Proof of residency, in the form, of a cc iy clyour drivers; lii.enst;, state identification, or utility bills are submitted.at the time of application.
Please note: The application iat Disability must be permanent a; submitted at the time of applica
Completed application forms may bo retu ned to: the office of youi alderman, any City of Chicago Department of Revenue facility, or via mail at P.O. Box 90311)0, CI icaf.0, IL 60680-31CO, ATTN: Disabled Permitting Section. A $25,00 maintenance, fee will be billed to you annually, Should 'ou lave questions or cc'ncsrris, please call our permit processing division at 312-744-PARK (7275).
1. Date of Birth
MO _ DAY
/ I O \ I I V II 9-
V Sta ? Idnntificaiion Numb'r
4. Applicant Last Name
H\0 \b\t W\f\oM
J.
3. Drivers License Number
J_J_L
Ml First Name
J\B\o \n\a/\i \e
S. Home Address (primary residence)
STREET NUMBER I OIK. I STREET NAME l
U I n i s j lu./l 0 I A IT l o l, A l o J n I \A....,/l.-=M
ZIP CODE
\L\A\/, i -C i / .
fMS- VJli^-.-f^fi-f*- - M-----
6. Address where signs will be posted
, STREET NUWBCR
H\0\3 \?\
DIR
STREET NAMfc'
7. Phone Numbers
?\o\r\o\/1UIH 1,4- ^1^-1 I I
Home
jZj!
Business
8. Current Permanent Disabled Placard Mumb r
9. Current License Plate Number
7
J____L
Registered to
_ Register id to
ft-ev\-e.e- o
City SticKer No.
If 36> 797-
Relationship to Applicant
Relationship to Applicant per e'e. (I. Ik}/ f11 a
~\i
iu. Description of Medical Condition and Disabi ty
■ » - vi -n^t^-i i i--jj.ir.-rw, ---«*»«... _t>--; :-t--■-"-------------
Alternative Parking1 Please note your applicatio i msy be denied if yo i havj alternative accessible off-street parking options.
11 .Is there otf-sireei parking available at your r: ima y residence (i.e., garage, car port, driveway, etc.)?
□ ves Eii
NO
12. If you answered Yes to question 11. please 1 esciioe. □ Garage; □ Driveway; □ Car Port □ Other.
13. Is your ofi-streel parking accessible?
□ Yes:
□ No Please explain;
14. Affirmation: I hereby affirm that the above ii forrralion is true and wwa. If the Cuy Dl Chicago Department oi Revenue delermines that the applicant has falsely represented one c mo c of the above.c editions, the applicant shall be subject to a ime ol not less than £100 but no more than S500. and the applicatic i sh ill be denied. I o.Uo understand that it is my responsibility to notify the Department ot Revenue of any changes in the information pro' idee
Signat
ure _ (?) Crrvru.JL. f^kff-^v-
._ Date ///^/tHOff
FOR OFFICE USE ONLY \/ \ /
n rep /\ ; i A.-ARn/Pi ATF WPr.QinPMnY L'j nOMPI PTF
City Council Meeting February 9,2011
MEMORANDUM FOR T RAfFIC REGULATION
PROHIBITION AGAINST PARKING (except for the disable)
NAME APPLICANT:
PRIMARY STREET ADDFES 5: LOCATION SIGNS TO BE POSTED: PERMIT: HOURS:
BONNIE J.ROBINSON
4037 W.POTOMAC 4037 W.POTOMAC 73604 ALL
DAYS:
ALL
Walter Burnett Jr, Alderman, 27th ward
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