APPUCATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
78027
An application will not be considered complete unless:
AD lines of the application have been completed in fii)
A check or money order for $70.00 made payable to t Please note: The application fee shall be waived for a <
Disability must be permanent as evidenced by a copy submitted at the time of application;
Proof of residency, in the form of a copy of your driver, time of application.
Completed application forms may be returned to: the office j ^
facility, or via mail at P.O. Box 803100, Chicago, IL 60680-j \
fee wffl be billed to you annually. Should you have questior < v
744-PARK (7275). V-
/enue enance at 312-
1. Date of Birth
MO _ DAY
2. State Identification Number
3. Drivers License Number
4. Applicant Last Name
Ml 1 Rrst Name
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5. Home Address (primary residence)
SIBEET NUMBER OW. I STREET NAME
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6. Address where signs will be posted
STHEET 8UWBER om. street name
WARO NUMBER
1.3 I 6
'^f. Phone Numbers
Home
Business
8. Current Permanent Disabled Placard Number
Registered to
Loners fie^^H
Relationship to Applicant
9. Current License Ptate Number
Registered to
City Sticker No.
Relationship to Applicant
s.
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10. Description of Medical Condition and Disability
atlon
; Atterrtative Parking: Please note your application may be denied if you have altemative accessible off-street parking options.
11. is there off-street parking available at your primary residence (Le., garage, car port, driveway, etc.)? _
YES
12. «f,y
13. is v
you answered Yes to question 11, please describe: Garage; □ Driveway; □ Car Port; , □ Other
13. Is your off-street parking accessible? -QYes; □ No. Please explain: ^ r/(y^<^(4^^
14, Affirmation: I hereby affirm thai the above information is true and correct. If the City of Chicago Department of Revenue deter/nines thai the (jppflcant has falsely represented one or more of the above conditions, the applicant shaft be subject to a fine of not less than SlOObut no more than $500, and the application shall be denied. 1 also understand that it is my responsibility to notify the rjepBrtrnenl of Revenue of any changes In the Information provided.
Signature.
Date
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JgTfESIDENCY □ COMPLETE , ~.i
Ir. {FOROFFICE USfiOtfLY
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□ PLACARD/PLATE
Uty ot Chicago Richard M. Daley, Mayor
Department of Revenue
Bea Reyna-Hickey Director
City Hall. Room 107A 121 North LaSalle Street Chicago. Illinois 60602-1288 (312) 747-4747 (IRIS) (312) 744-0471 (FAX) (312) 744-2975 (TTY)
January 12, 2011
ALDERMAN JOHN RICE WARD 36
6839 W BELMONT AVE. CHICAGO, IL 60634
Dear ALDERMAN RICE:
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: LORETTA PIECUCH Applicant's Address: 3740 N OAKPARK AVE
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(/Gambiho Manager of Parking
A.
cc: Mayor's Office for People with Disabilities