MEMORANDUM FOR TRAFFIC REGULATIONS PROHIBITION AGAINST PARKING (Except for the Handicapped):
Street, etc: West Morse Avenue
Location, etc: No. 2724 (Permit No. 119278)
Distance or extent:
Hours: at all times
Days: no exceptions
JOHN N. STONE
Alderman, 50th Ward
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
490-002 02/14
119278
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
2 State Identification Number
1. Date of Birth
MO DAY
0 I % I ^ I
4 Applicant Last Name
SITIO I N I E I
STREET NAME
5 Home Address (primary residence)
STREET NUMBER
STREET NAME
M0-
-VI.
7 Address where signs will be posted
STREET NUMBER
Home
a.|-q-|-a-|H-
8. Phone Numbers
i n i -3i aifc m ?>\s
9. Current Permanent Disabled Placard Number
bT3 "76 | 9.3
10 Current License Plate Number of Vehicle that will be parked in the space: 5 | ^ g £ £ U| 1
, WARD NUMBER
5S0
Relationship to Applicant
Relationship to Applicant Stlf
11 Does the registered owner of the vehicle reside at the address of the applicant?
12. Provide a Description of Medical Condition and Disability
Alternative Parking Please note your application may be denied if you have alternative accessible off-street parking options
13. Is there off-street parking available at your primary residence
(i.e., garage, car port, driveway, etc.)?
4. If you answered Yes to question 13, please describe the alternative parking available: Sf Garage, □ Driveway, □ Car Port, □ Other
15 If alternative parking is available, why are you unable to access the space? Please explain
ES □ NO If yes, what type do you use?
Crar^e. \s -\bp -far fVtM 6lq6V without" :?feps. s& un Acces<bU^
16 Do you use assisted devices? STYES □ N
17 Are you able to walk 200ft? □ YES ISTno If no, why? ^>a[y^ + \ ^ ^ -f ^ [, * ( ,*-(- ^
Affirmation: Under penalties provided by law pursuant to Section 1-109 ol 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 $500 and not more than S1.000, plus three times the city's damages, litigation costs, collection costs and attorney's fees I acknowledge that providing false information on this application or omitting matenal 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 in the information provided or I may be subject to a Denatty of not less than S100 and not more than S500, under Section 9-64-050 (f) of the Municipal Code ot Chicago.
Date.
Signature .
77, 6