APPLICATION FOR DISABLED PARKING SIGNS 73249 PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE -FORM
An application will not be considered complete unless:
All lines ol the application have been completed in full; * A check or money order for $70.00 made payable to the,City of Chicago is submitted as'payment of the application fee;
Please note: The applicalion fee shall be waived for any parson holding a valid, current disabled veterans piste.
Disability must be permanent as evidenced by a copy of your valid disabled placard and/or current vehicle registration
submitted al the time of.appjtcation;
Proof o! residency, in the 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 Oepanmenl of Revenue facility, or via mail at P.O. Box 803100. Chicago, IL 60680-3100. ATTN: Disabled Permitting Section, A S25.00 maintenance fee will be billed lo you annually. Should you have questions or concerns, please call our permit processing division at 312-744-PARK (7275).
1. Oate of Birth
2. Slide Identification Numbor
3. Drivers License Number
4. Applicant Last Name
Ml
n
First Name
5. Home Address (primary residence)
. STAEtT NUMBER OH.' STHECT fj*»:f.
b\&\<e\t i 1
H. Address where sryns v.'ill be posted
STREET NUMClR
, V.'AHI; HtfMSi
(1IR
STOEET HAhtC
7. Pnone Numbers
Home
l_12j^M.i^i^_i./J.^
8. Current Permanom Disabled Placard Number
9. Curren! License Plate Numbor
X J ? 34^3
Business
Regtstcred to /? , r- //_____
Registered to
City SticKor No.
Relationship to Applicant
Relationship to Applicant
10. Description of Medical Condition and Disability
Alternative Parking: Please hoto your application may be deniod if you have alternative accessible off-stfeet parking options.
11. is there off-street parking available'at your primary residence "S^YES □ NO (i.e., garage, car port, driveway, etc.)7
1?. It you answered Yes to question 11 please describe: -Si Garage: □ Driveway: Ci Car Port; □other
parking accessible'? T^it'C Qle> Z>^ Qfr/eJ 7^> ft ?&e~ tttfy £lj~
No. Please explain; i>ee« t/Stf <S> F.p^ h e« 7^ <&*UcL tf&/><s/e>*^it~
13. Is your off-street . □ Yes; 21
14. Affirmation: I hereby affirm that the above information Is true and correct, tf the City ol Chicago Department ol Revenue determines thai Ihe applicant has falsely represented one or more of theabovo conditions, the applicant shall be subject to a fine of not less than $100 but rio more than $500, and the application shall be denied. I also understand thai it is my responsibility to notify the Department: ol Revenue of any changes in the information provided.
Signature
Datc
□ COMPLETE $$>"](). -
FOR OFFICE USE
JNLY
FEE
^^PLACARD/PLATE
□ RESIDENCY
ALDERMAN MICHELLE A. HARRIS WARD 08
8539 S COTTAGE GROVE CHICAGO, IL 60619
January 4, 2011
Dear ALDERMAN HARRIS:
The Department of Revenue received a request for disabled parking signs to be posted in your ward. The application has been reviewed and a survey of the location has been conducted. The Department cannot recommend the application.
Provided is the name and address of the applicant, the proposed location of the signs, and the Department's reason for not recommending the application.
Applicant's Name: REGINA F HARRIS Applicant's Address: 8951 S EUCLID
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 our office at 312.742.7434.
Very truly yours/
Anthony Gambino Manager of Parking
cc: Mayor's Office for People with Disabilities