MEMORANDUM FOR TRAFFIC REGULATIONS
OVERRIDE
PROHIBITION AGAINST PARKING (Except for the Handicapped):
Street, etc:
South Hemitage Avenue
Location, etc:
No. 8610
(Permit No. 71058)
Distance or extent:
Hours:
at all times
Days:
no exceptions
WILLIAM S. SHEETS
LONA LANE Alderman, 18th Ward
APPLICATION FOR DISABLED PARKING SIGNS 71058 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 lor $70 00 made payable to the City oi 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 lhe 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 $25.00 maintenance fee will be billed to you annually. Should you have questions or concerns, please call our permit processing division at 312-744-PARK (7275).
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3. Drivers License Number |
4, Applicant Last Name |
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First Name |
5. Home Address (primary residence) |
6. Address where signs will be posted |
, WARD NUMBER |
7, Phone Numbers Home |
3 .0 |
Business --11 T 1 "1TT 1 1 |
m. Current Permanent Disabled Placard Number |
Registered to |
Relationship to Applicant _ |
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9. Current License Plate Number |
Registered to \a)> Sheets |
Cily Sticker No. |
Relationship to Applicant |
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10. Description of Medical Condition and Disability fco /U-~ S |
Alternative Parking: Please note your application may be denied if you have alternative accessible ofl-street parking options. |
11, Is there off-street parking available at your primary residence J^TyeS <fl^NO (i.e., garage, car port, driveway, etc.)? |
12 Ifyou answered Yes to question 11, please describe: 3 Garage; □Driveway; □ Car Port; □Other: Uo*-^ fav Pf~£$rC/J1~ OuJAJ-Cf / ■--- ■---' 1 7 ' |
13. Is your off-streetparking accessible? r\s" j^^rcs: ^£&o Please explain: |
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14. Affirmation; I hereby affirm that the above information is Irue 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 nol 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 Jlj/j//^ ^Ai2 .........___________ Date l^^"^
FOR OFFICE USE ONLY
□ FEE □ PLACARD/PLATE □ RESIDENCY □ COMPLETE
PEOPLES GAS
ACCOUNT NUMBER: 0 5000 2246 3643
BUDGET AMOUNT OF $170 00 WILL BE SENT TO BANK FOR AUTOMATIC PAYMENT ON 09/30/2010
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WILLIAM SHEETS
B610 S HERMITAGE AVE
CHICAGO IL 60620-4839
PEOPLES GAS CHICAGO IL 60687-0001
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Yes, I would like to pledge one dollar per month to the
Share the Warmth fund which helps low-income customers payenergy bills.
I have added one dollar to my payment. Check this box -> |~1
Please do not write or stamp below this line.
^505000224b3bM3000Qr>DaODD01700000000
Gas Charge $53500 x 26.20 Therms
Efficiency Program
Environmental Charge soowo * 26.20 Therm*
$14.02 SO 45 $0 09