City of Chicago Richard M. Daley, Mayor
Department of Revenue
Hugh P. Murphy Director
CiiyHall, Room 107 121 North LaSalle Street Chicago, Illinois 60602 (312)?'W-6I46 (3l2)7'M-047l (FAX) (312)744-2975 (TTY)
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BUI OUNf. CHICAGO TOGETHER
DISABLED PERMIT PARKING
REMOVAL APPLICATION
FOR SIGN REMOVAL REGARDING PROHIBITED PARKING
EXCEPT FOR DISABLED PERMIT NUMBER "f^ir Jlg
(Please print or type.)
NAME OF DISABLED INDIVIDUAL: Ag cta A *
REMOVAL LOCATION OF DISABLED PARKING SPACE REQUESTED:
1HQH S. Kernc-H-
(Please print or type current sign location address.) CHICAGO, ILLINOIS ( ZIP CODE) botiUt (PHONE NUMBER) REASON FOR REMOVAL: ^ ,r, & o~ S^nl
NAME AND ADDRESS OF PERSON CURRENTLY BEING BILLED FOR ANNUAL SIGN MAINTENANCE FEE: 7 ¥t» V $* ^^
(Please provide information only if billing information differs.)
ILLINOIS VEHICLE T .TCENSE NUMBER: ^f-/^ 3 ^
(W or V plates)
ILLINOIS DISABLED PLACARD NUMBER: ^ /2266>_
(Secretary of State Disabled Placard)
CERTIFICATION; THE ABOVE INFORMATION IS CORRECT TO THE
BEST OF MY KNOWLEDGE: An*+£. /JZ.^^
(Signature of Applicant)
FORWARD THIS COMPLETED APPLICATION TO YOUR ALDERMAN.
APPLICANT: DO NOT WRITE BELOW THIS LINE
ALDERMANIC CERTIFICATION:
(AJdermaiuc Signature)
(Ward)
(Date)
AFTER APPROVAL, THIS APPLICATION IS TO BE FORWARDED TO COUNCIL SERVICES, BY THE ALDERMAN, AT THE TIME THE DISABLED SIGN REMOVAL ORDINANCE IS INTRODUCED.
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FEMALES
^OATE.9P0EATH.VC;J;'
-li;jUNE 22; 20l6 'l
COUNTY OF DEATH^!^lH;^^r! AGE AT. LAST BIRTHDAY^Ue ^ ]j'^Syj-7i^A^'Ui'^i.-. /:MTE-OFjBIRTH;^WrM^^i1i-^^L^llilc:!>-:
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HOSPITAL OR OTHER INSTITUTION NAME'!•*•.;***•¦'•>/•'.w£-;~?;;V?-Vv:f;V
CHRIST HOSPITAL & MED CNTR v-^:- ^r^,:'^
PLACE OF DEATH • , " INPATIENT
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