MEMORANDUM FOR TRAFFIC REGULATIONS
PROHIBITION AGAINST PARKING (Except for the Handicapped):
Street, etc: North Seelev Avenue
Location, etc: No. 6720 (Permit No. 98606)
Distance or extent:
Hours: at all times
Days: no exceptions
NICOLE KETTANEH
J4IDMDUIOW/
490-002 02/14
APPLICATION FOR DISABLED PARKING SIGNS 98606 PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
An application will not be considered complete unless: All lines of the application have been completed in full;
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, state issued medical card,
or the following utility bills: Peoples Gas, ComEd, or City of Chicago water bill 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 Finance facility, or via mail at P.O. Box 803100, Chicago, IL 60680-3100, ATTN: Disabled Permitting Section. A $25.00 maintenance fee will be billed to you annually. Should you have questions or concerns, please call our permit processing division at 312-744-PARK (7275).
3. Drivers License Number
1 Date of Birth
MO DAY
YEAR
First Name
o i a i o \a- \n iy
4. Applicant Last Name
2. State Identification Number
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5 Home Address (primary residence)
STREET NUMBER DIR SIREET NAME
il\l\C\t>\L\£\ I I
| ZIP CODE
\Q>\0\h\H\S
6. Do you rent or own?
□ RENT afOWN □ OTHER
. WARD NUMBER
Business
7 Address where signs will be posted
STREET NUMBER | DiR I STREET NAME
oi reel 'NuiviDcn uih amt=l i^iAivit . t
Home
b\n\%\o\ M^\£\£\L\£-\y\
8. Phone Numbers
Registered to
Relationship to Applicant
9. Current Permanent Disabled Placard Number
egislered to
City Sticker No.
Relationship to Applicant
tL
YES □ NO
11 Does the registered owner of the vehicle reside at the address of the applicant?
10 Current License Plate Number of Vehicle that will be
parked in the space: ^/s~j / Q-J'
□ Temporary
12 Provide a Description of Medical Condition and Disability muf/ln^ A&rfiA. 0/t'ermanent disability
Tioti A>A £*i*£fl£ BIWw \>t$Wt?A men cAutes &XT££ffllL
Alternative Parking Please note your application may be denied if you have alternative accessible off-street parking options
□ YES Bfr
NO
13. Is there off-street parking available at your primary residence (i e., garage, car port, driveway, etc.)?
14.If you answered Yes to question 13, please describe the alternative parking available. □ Garage, □ Driveway, □ Car Port; □ Other.
15. If alternative parking is available, why are you unable to access the space? Please explain:
16 Do you use assisted devices? □ YES 3 NO If yes, what type do you use?
,7 A. yoUaM SCOPES rfNO fiWV^g&'WVXy.
Date
Affirmation: Under penalties provided by law pursuant to Section 1-109 of the Code of Civil Procedure. I hereby certify and attest that the statements set forth in this document are true and correct. I acknowledge that, pursuant to Section 1-21-010 of the Municipal Code of Chicago, persons who make material false statements on this application may be fined not less than S500 and not more than S1,000, plus three times the city's damages, litigation costs, collection cosis and attorney's fees I acknowledge that providing false information on this application or omitting material information from this application may result in denial of the application. I also understand that it is my responsibility to immediately notify the Department of Finance of any changes ipjhe informatiorvproyidjed or I may be subject to a penalty of not less than S100 and not more than S500, under Section 9-64-^050 (f) o^ the Municipal Code of Chicago.
Signature.
FOR OFFICE USE ONLY
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