Cit> of Chicago Richard M. Daley. Ma\or
Department ul Revenue
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DISABLED PERMIT PARKING
REMOVAL APPLICATION
FOR SIGN REMOVAL REGARDING PROHIBITED PARKING
EXCEPT FOR DISABLED PERMIT NUMBER
30482
( Please print or type.)
NAME OF DISABLED INDIVIDUAL:
REMOVAL LOCATION OF DISABLED PARKING SPACE REQUESTED:
3825 WEST 68TH PLACE
( Please print or type current sign location address.)
CHICAGO, ILLINOIS (ZD?CODE) 60629 (PHONENUMBER)_
REASON FOR REMOVAL:_DECEASED_
NAME AND ADDRESS OF PERSON CURRENTLY BEING BILLED FOR ANNUAL SIGN MAINTENANCE FEE:_
(Please provide information only if billing information differs.) ILLINOIS VEHICLE LICENSE NUMBER:_
(W or V plates)
ILLINOIS DISABLED PLACARD NUMBER.
(Secretary of State Disabled Placard)
CERTIFICATION: THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE:_
(Signature of Applicant) FORWARD THIS COMPLETED APPLICATION TO YOUR ALDERMAN. APPLICANT: DO NOT WRITE BELOW THIS LINE
ALDERMANIC CERTIFICATION:
(Aldermanic Signature)
13 2/9/11
(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.