49040! 1M7/05
APPLICATION FOR DISABLED PARKING SIGNS 76667 PUEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
An application will not be considered complete unless: ■ All lines of the application haye been compjeted in full;
A check or money order for $70.00 made payable to the City of Chicago is submitted as payment of the application fee; Please note: The application fee shall be waived for any person holding a valid, current disabled veterans plate;
Disability must be permanent as evidenced by a copy of your valid disabled placard and/or current vehicle registration submitted at the time of application;
Proof of residency, in the form of a copy of your drivers license, state identification, or utility bills are submitted at the time of application.
. Completed application forms may;be returned to: the office of your alderman, any City of Chicago Department of Revenue )\ijfy$mjfi or via mail at P.O;jBox 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 permit processing division at 312-
744-PARK (7275).
1. Date of Birth
2. State Identification Number
3. Drivers License Number
it
4. Applicant Last Name
Ml I FirstName
eMiWiftLifiSi
;s;/Home Address (primary residence)
<js. Address where skjns will be posted REerHiweifn ' t on -'-
g ZIP CODE
mil
WARD NUMBER
W-:
j£ ■Pholie Numbers Home
Business
8. Current Permanent Disabled Placard Number
I Registered to^ /
Relationship to Applicant
9. Current License Plate Number
Registered to
City Sticker No.
Relationship is, Applicant
l w*i^w**»jiiptlOn Of MGCJiC^t a^wi iubuwi i wiu LfMawm^ i f i I
Alternative Parking: Please note your application may be denied if you have altemative accessible off-street parking options.
Hon and Disability
m
i : k
i
il , is triers off^ree^/parklng available at your primary residence $i%^^^t^^^^-^^Vf etc;)?
□ YES 2Lho
12 tf yp^ ansWered Vves to question 11, please describe:
i □parage;. ■ Qi:6riveway; Q Car Port; □ Other.
13. Is youttoff istieetl □ *es:
^filase explain: -\^Us& S <* ^jUgl IA~ Mutt GahJ ArJ to h^H Qj&
14; Affirmation: I hereby, ajflrm that the above information is true and correct. If the City of Chicago Department of Revenue determines >f^$it:ttkS'f«^p9ic>Qflit ~Ac|S:^iis^y-«^pviosente(iroriet or more of the above conditions, the applicant shall be subject to a fine of not less than $.100 btrt no more than $500, and ^application stjan be denied. I also understand that ft is my responsibility to notify the Department of Revenue of any changes m the Information provid
Signatui
Date
□ COMPLETE 1
FOB OFFICE USSQNLY
LACARD/PLATE
ESIDENCY
City of Chicago Richard M. Daley, Mayor
December 22, 2010
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)
ALDERMAN SHARON DIXON WARD 24
2100 S MARSHALL BLVD #801 CHICAGO, IL 60623
Dear ALDERMAN DIXON:
The Department of Revenue recommends installation of disabled parking signs as described below. The application has been reviewed and a survey of the location has been conducted. Since the applicant has met the requirements outlined in the Municipal Code, the signs will be installed.
Provided is the name and address of the applicant, the exact location proposed for the signs, and the permit number assigned. Please introduce an ordinance to post residential disabled parking signs at the location recommended, if one has not yet been introduced.
Applicant's Name: CHARLES E GARDNER
Applicant's Address: 3929 W POLK Address/Location of Signs: 3929 W POLK
Permit Number: 76667
Work Order Number: H10-1472
If the proposed ordinance is not passed within four months after its introduction, the permit shall be revoked and the restricted parking signs removed. 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
Enclosure: Disabled Signs Application
City of Chicago Richard M. Daley, Mayor
December 22, 2010
Department of Revenue
Bea Reyna-Hickey Director
CHARLES E GARDNER 3929 W POLK CHICAGO, IL 60624 .
City Hall, Room 107A 121 North LaSalle Street
Chicago, Illinois 60602-1288
Dear Applicant:
(312) 747-4747 (IRIS) (312) 7.44-0471 (FAX) (312) 744-2975 (TTY)
The Department of Revenue has recommended installation of disabled parking signs near your residence. Based on this recommendation, the signs for your restricted parking space will be installed. However, your application must be approved by City Council. If the proposed ordinance is not passed within four months after its introduction, the permit shall be revoked and the restricted parking signs removed.
The parking permit must be renewed annually. The fee is $25.00. A renewal notice will be mailed one year from the date the signs are installed.
Please be advised that you are required to report any changes to the information provided on your original application to the City of Chicago Department of Revenue. You are also required by City law to notify the Department if you no longer meet the following permit qualifications:
* You must hold either a valid, current disabled veteran's state registration plate or permanent person with disability license plate, permanent parking placard or device authorized by the Illinois Vehicle Code;
* Any vehicle parked by you or for you in the designated area must bear the disabled license plate, permanent disabled parking placard or devices issued to you by the State
* You must continue to reside at the home address listed on the original application.
A residential disabled parking permit will be issued to you by the City of Chicago. It must be placed on the right side of the dashboard. Only qualified vehicles displaying the permit are authorized to park in your restricted parking space. The permit number must be visible from outside your vehicle. The permit will be installed at:
Address/Location of Signs: 3929 W POLK Permit number: 76667
Should you have any questions or require additional information, please contact the City of Chicago's Helpline at 312.742,7434.
Very truU^yourSr-. _.
of Illinois;
Anthony Gambino Manager of Parking
DS
Copy: ALDERMAN DIXON