MEMORANDUM FOR TRAFFIC REGULATIONS
Over-Ride
PROHIBITION AGAINST PARKING EXCEPT FOR THE DISABLED Name Applicant: Maria Magana
Primary Street Address 5239 S. Kostner Ave., Chicago, II. 60632
Location Signs to be Posted: 5239 S. Kostner Ave
Permit # 77793
Work Order Number:
Hours: At all times
Days: No Exceptions
City Council Meeting January 13, 2011
23rd Ward Alderman
APPLICATION FOR DISABLED PARKING SIGNS 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, 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 fA2. State Identification Number
A MO , _ DAY _ viYEAR;:<■''''[ 5y _w_ _
A. Applicant Last Name
3. Drivers License Number
Ml
First Name
5. Home Address (primary residence)
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I ZIP CODE
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6. Address where signs will be posted
f STREETNUMBER I I STREE/T NAME , , 1 ,
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7. Phone Numbers Home
,, WARD NUMBER
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Business
8. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
9. Current License Plate Number
Registered to
City Sticker No.
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Relationship to Applicant
10. Description of Medical Condition and Disability LfW< o£ (} /f(lsTltA br£ /h/(0
) 0
Allernative Parking: Please note your application may be denied if you have alternative accessible off-streerparking options
11. Is there off-street parking available at your primary residence (i.e., garage, car port, driveway, etc.)?
□ YES
NO
12. If you answered Yes to question 11, please describe:
□ Garage; □ Driveway; □ Car Port; □ Other:
13.1s your off-street parking accessible? , .-.■«* d-^s;: :'a^;^iif:>if
Yes; feW Please explam: /t^c^^^
14. Affirmation: I hereby affirm that the above information is true and correct. If the City of Chicago Department of Revenue determines that the applicant has falsely represented one or more of the above conditions, the applicant shall be subject to a fine 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.
FOR OFFICE USBQNLY
AAFEE
□ PLACARD/PLATE □ RESIDENCY □ COMPLETE V /(J