City Council Meeting January 13,2010
MEMORANDUM FOR T RAFFIC REGULATION
PROHIBITION AGAINST PARKING (esi:ep< for tbe disable)
NAME APPLICANT:
PRIMARY STREET ADDRESS: LOCATION SIGNS 10 BE POSTED: PERMIT: HOURS:
BETTY F.TABBWALKER
343 W. OLD TOWN COURT 1211 N.SEDGWICK 73«36 ALL
DAYS:
ALL
Walter Burnett Jr, Alderman, 27th ward
APPLICATIDN FOR DIS/.BLED PARKING SIGNS PLEASE HEAD THE FOLLOWING CAREFULLY BEF< )R E COMPLETING THE FORM
73636
An application will not be considered corr 5let> unless.
All lines of the application have been :orr pleted in full;
A check or money order for S70.00 rr ade payable to the Please note; The application feu shal be waived for any
. Disability must be permanent a:; evid >nc< o by a copy of submitted at the time of application;
Proof of residency, in (he form of a c< py < f your drivers Ii::ens2, state identification, or utility bills ai'e.:$ubrnitted.a! the time of applicalion.
Z'ny of Chicago is submitted as payment of the application fee; aerson holding a valid, current disabled veterans plate, /our valid disabled placard and/or current vehicle regislration
Completed application forms may be retu nec to: the ofdc« o facility, or via mail at P.O. Box 8031 DO, C licaijo, IL 60680-31 fee will be billed to you annually. Siould /ou have question:; 744-PARK (7275).
your alderman, any City of Chicago Department of Revenue :>0, PTTN' Disabled Permitting Section. A $25.00 maintenance or cjncerns, please call our permit processing division at 312-
.1 'V
Date of Birth
MO PAY
4. Applicant Last Name
2. Str le Ic entification Numi
J_LJlLLlJ
L_L
er
iL. L.
3. Drivers License Number
l/l 4 Iff I £1^1 9 \rO \¥\*?\t\l.<£ '
First Name
1
5 Home Address (primary residence)
STREET NUMBER DIR. STKEET NAME
3W\3\ \u\ 1 V\ I 1 dj i \ \e\\v\.f\\
6. Address where signs will be posted
S'lWEET NUMBER | IJIR STHEE'I NAME
7. phone Numbers Home-^
1ZI» CODE i.\o\(e\ m
itfieiern mim
Bl siness
S ft X\ 3 I 9 \n i n " 1 6 JJL
8. Current Permanent Disabled Placart Numl er
ft 6c 07 #1%____
9. Current License Plate Number
rifle g-l-6?.
WAHO NUMBljrt
%n 1
Fiegistered to
Registered to
City SlicKer No.
Relationship to Applicant
Relationship to Applicant
10. Description of Meoical Condition and Disal ility
______^OQ* i \ '{jL tl^______
Alternative Parking: Please note your applicat >n niay be denied il;,:>u rawe alternative accessible off-street parking options.
IjifYES □ NO
11. Is there off-street parking available rit your pnrrary residence (i.e garage, car port, driveway, etc[?___
12.11 you answered Yes to question 11, pleasi describe:
S3 Garage; □ Driveway; □ Oar Pel; IJ Other:
13.1s your off-street parking accessible ^ □ Yes; □ No Please explain:
H, Affirmation: I hereby affirm tnai the above info mation is irue ard correct. If the Ciiy ol Chicago Department of Revenue determines that ihe applicant has falsely represented one or r iore ol the above cone itions, the applicant shall be subject to a line of not less than $100 but no more than $500. and the applica ion : hall be denied. I :ilsc understand that it is my responsibility to notify the Department of Revenue of any changes in th9 inlonration p avid id.
Signature,.(
Date.
FOR OFFICE USE ONLY
□ FEE
PLACARD/PLATE □ RESIDENCY U COMPLETE