application for disabled parking signs please read the following carefully Before completing the form
77410
Arrap^caTion will not bte fiAhgidered complete unless:
• All lines of the applicam^ri have been completed in full;
• A check or money onjrer 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).
1. Date of Birth MO _ DAY _ YEAR 0 lS I 2- [M I 1 (S |
2. State Identification Number |
3. Drivers License Number p| 1 Kb lib 1 d b 1 s lt> |e> \(o |
4. Applicant Last Name \ 1 Pi alU \ lo 1 1 1 1 1 1 1 1 1 1 1 |
Ml |
First Name &i 1 5) b 1 T | "i e 1 1 1 |
5. Home Address (pri STREET NUMBER 2 11 IS k 1 |
mary DIR. V |
residence) STREET NAME II ?lp CODE NMrlal Kkkl^ldvl 1 1 1 1 1 1 kl^lU^la |
6. Address where sig STREET NUMBER 2-J 1 IsJ H 1 |
ns w DIR. |
II be posted STREET NAME IH l?Jr IcA 1 IS Mr |
WARD NUMBER e. \? Kl- 1 1 1 1 1 1 1 1 II 1 1 |
7. Phone Numbers Home 1 1 1 b 1 5 1 2 1 ^ 1 1 H |
c\ 1 I |
Business |
8. Current Permanent Disabled Placard Number |
. Registered to |
Relationship to Applicant |
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9. Current License Plate Number |
Registered to |
City Sticker No. |
Relationship to Applicant |
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10. Description of Medical Condition and Disability
p frig ~TJy-ot)\j2.»-->n
Alternative Parking: Please note your application may be denied if you have alternative accessible off-street parking options.
CYyes
11. Is there off-street parking available at your primary residence (i.e., garage, car port, driveway, etc.)?
□ no
12. If you answered Yes to question 11, please describe:
Garage; □ Driveway; □ Car Port; □ Other:
TVryV r^g.\uw^-h> wis. ,
UV\QH
CXjGrvfiV
13.1s your off-street parking accessible? □ Yes; □ No. Please explain:
14. Affirmation: I hereby affirm that the above information is true and correct. If the City of Chicago Department ol Revenue determines that the applicant has falsely represented one or more of the above conditions, the applicant shall be subject to a line 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 of Revenue of any changes in the information provided.
Signature Yg/^-^
Date X
/-/?- II
:OR OFFICE USE ONLY
□ FEE
□ PLACARD/PLATE □ RESIDENCY
□ COMPLETE
'i>-r-cr<owl,"'-«<-l'>-l»,loljri«l>(^ciUtP(lll-IUAIIUNi;AKL)
irmabve Insurance Company mait
0 harvester r»*ye, Burr Ridge, IL 60527-5965 4Z0OT
EFFECTIVE DATE: 12/10/2010 EXPIRATION DATE: 12/10/2011 SUREDfGabriel Pablo H.ICY NUMBER: 0005220170000
AR MAKE 98 Pontiac
MODEL
Trans Sport SE/Trans S 1VERAGE: Bl. PD, UMBI, MED
VIN
1GMDX03EXWD16213-
ODUCER: InsureOne - 313
THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND _PRESENTED UPON DEMAND
REMOVE BEFORE VEHICLE IS IN MOTION. THIS PLACARD IS NOTTRANSFERABLE. IT IS ILLEGALTO COPY OR DUPLICATE THIS PLACARD.
THE AUTHORIZED HOLDER MUST BE PRESENT AND MUST ENTER OR EXIT THE VEHICLE AT THE TIME THE PARKING PRIVILEGES ARE. BEING USED. UNAUTHORIZED USE MAY RESULT IN A S500 FINE AND SUSPENSION OF DRIVER'S LICENSE AND/OR REVOCATION OFTHE PLACARD.
IL PERSONAL AUTO INSURANCE IDENTIFICATION CARD Affirmative Insurance Company NAIC #: 42M9
150 Harvester Drive, Burr Ridge, IL 60527-5965
EFFECTIVE DATE: 12/10/2010 EXPIRATION DATE: 12/10/2011
I
INSURED: Gabriel Pablo
POLICY NUMBER: 0005220170000
YEAR MAKE 2003 Mitsubishi
MODEL
Outlander XLS A WD
V1N
JA4LZ41G23U040075
COVERAGE: Bl, PD, UMBI, MED
PRODUCER: InsureOne - 313
THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND
Jessa White* Secretary of Slots
ID CARP
n>:*>, H02-8075O86P
fxpiro* 03<£&2T'
SJ8*!£LMBt
>4.W-43|§.JT ,
truss: M2A Type-. DISABLED
JMoJe 5'^'' 200 lbs BUM Eyes
i DRWEITSHCENSE
cw *«.: P14Q-2807-5086
,ExpirW03<2&*? . im.-ICA601lx(>0E32
PERMANENT
.3 0 0 unN3sE
i /
8
8
EXPIRES THE LAS
\9J£
Jan. Feb. Mar. Apr. May June
;PAY-TOTHE_ .ORDER OF ,
CITY OF CHICAGO t*tt*ttsE\7EHTY AND 00/100 U.S. Dollars*******
:;v:,.; WARNING:- DO NOT ACCEPT THIS DOCUMENT UNLESSYOU CANiSEE' ATRUE WATERMARK AND VISIBLEpJEiERS FROM BOTH SIDES
I I 1 -
ipplication fee;
j plate.
e registration
nitted at the
it of Revenue 0 maintenance division at 312-
5 it> is kg
MEMORANDUM FOR TRAFFIC REGULATIONS
PROHIBITION AGAINST PARKING (Except for the Handicapped):
Street, etc:
West 43rd Street
Location, etc:
No. 2754
(Permit No. 77410)
Distance or extent:
Hours:
at all times
Days:
no exceptions
GABRIEL PABLO
GEORGE A. CARDENAS Alderman, 12th Ward