\
- r*/21/20li- 15:07
7737362333
'3 i O
City of Chicago Ricluni M. Daley, Mayor
January 3, 2011
Department nf Revenue
Bea Keyita-Hickcy Director
MINDA A BANCOLITA 4829 N KILPATRICK AVE CHICAGO. IL 60630
City Hall, Room I07A 121 North LaSalle Street
Chicugo, Illinois 60602-1288
Dear Applicant.
. (312) 7474747 (IRIS) (312) 744-0471 (FAX) (312) 744-2975 (TTY)
The Department of Revenue received your request for disabled parking signs. The application was reviewed and a survey of the location was conducted. The Department cannot recommend the application.
ht tp://*ww ,ci I yol'cli icneo -0 i'S
The Department's reason for not recommending the application is:
Reason Not-Recommended: ALTERNATIVE ACCESSIBLE PARKING Explanation: GARAGE AT LOCATION
Appeals must be filed within ten (10) days. Appeal requests must be made in writing and state reasons to support a request for a review. Appeals may be directed to the Mayor's Office for People with Disabilities (MOPD), Disabled Parking Signs Appeal, City Hall. Room 104, 121 N. LaSalle St., Chicago, IL 60602. A decision regarding an appeal will be made within thirty (30) days of the request. Applicants are notified by mail of the final decision.
Should you have any questions or require additional information, please contact us at (312) 742-7434.
Very truly yours,
Anthony Gambino Manager of Parking
uJMNC CIHCVIIJ Toravnn*
-81/21/2011 15:07 7737362333
PAGE 02/02
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
77033
An application will not be considered complete unless: All lines of the application have been completed in full;
« A Chech 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 ptate.
Disability must be permanent as evidenced by a copy of your valid disabled placard and/or current vehicle registration
submitted at the lime of application; ■ Proof of residency, in tlie 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 parmil processing division at 312-744-PARK (7275).
1. Data of Birth MO _ DAY _ YEAR Ml I 3 I e> I fl' |£> . |
2. State Identification Number fte\H\tti\t\a\MM\66 |
3. Drivers License Number 1 1 1 T l I I T I I I |
4. Applicant Last Name ~ | Ml MMtiloldlMilTlM 1 II 1 1 1 1 r |
First Name tohM-piAi I I I I I i |
5. Home Address (primary residence) STREET NUMBS* ■ 1 OIFV | STREET NAME 11 2" COOE |
6. Address whera signs will be posted STREET MUWBEH I OIB. | STREET NAME f IfcH-K 1 U 1 V-l \ 1 M t>l M~U fc-M |
-WARD NUMGEn c-1 VI 1 1 1 1 1 1 1 1 1 1 1 1 |
7. Phona Numbers Home n 13 TOlZ 1ST I P |
|
Business . 1 I T 1 I T I I I |
8. Current Permanent Disabled Placard Number |
Registered lo |
Relationship to Applicant |
|
|
|
9. Current Licensa Ptate Number |
Registered to |
City Sticker No. |
Relationship to Applicant |
|
|
|
|
10.Description of Medical Condition and Disability |
Alternative Perking: Please note your application may be denied II you have alternative accessible olf-strest parking options. |
11.1s there ofl-street parking available at your primary residence □ YES Q NO (i.e., garage, carport, driveway, etc.)? |
12. If you answered Yes to question 11, please describe: I'J Garage; □ Driveway; □ Car Port: O Oilier: |
13. Is your olf-sireet pailiing accessible? Q Yes; Q No. Please explain: |
|
|
|
|
|
|
|
|
14. Affirmation: I hereby allirm that the above information is true and correct. If the Cily ol Chicago Department of Revenue determines lhat Iho applicant has falsely represented one or more of the above conditions, the applicant shall be subject lo a line of not less than $100 but no more than $500, and the application shell be denied. I also understand that it Is my responsibility to notify the Department ol Revenue of any changes in the information provided.
Signature H ,'hdO~A' l5*-p7 I t +0
Date //" tis^m-efO
FOR OFFICE USE ONLY □ FEE
□ PLACARD/PLATE □ RESIDENCY
□ COMPLETE
Disabled Parking Application Payment Stub'.
Please make check or money order payable to the Cily of Chicago or
when paying with a credit card, please fill in the following information.
IMS MYMEUT WILL MOT BE PROCESSED IF HOT SIGNED
Card No.
s |
|
6 |
6 |
|
|
/ |
0 |
5 |
|
9 |
6. |
|
|
<# |
9- Date |
/ |
0 |
- |
/ |
/ |
□
Signature:
By signing Iwr ■ ngree in ihe term* ami condition! nf thl* noltat
flEASe
> no NOT Mndcah
■ on not lew im ptf mam «Mif»
DO WOT Ettfpfe lr>« chick or moncr onto (a (Tie
TOTAL AMOUNT DUE
70.00
PAYMENT AMOUNT ENCLOSED
to ueuriE morel credit please beiubn tkii srui with mm pavhent
OOQQD0?7D33?OQ0"1