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City ©r Chicago Richard M. Unlej, Mayor
DcpAitincnt of Revenue
Ben R!>jn«-Hltkey Director
City Hall, Room 107 121 North LnSnlkSliMl Cbicn^o, lllinobi
(312)747-4747 (IRIS) (112)744-0471 (FAX) (312)744.2973 (VYY)
hup://*ww.cityoftliiea|W.ors
DISABLED PERMIT PARKING
REMOVAL APPLICATION
FOR SION REMOVAL REGARDING PROHIBITED PARKING
EXCEPT FOR DISABLED PERMIT NUMBER: 61 3£A
(Please print or type.)
NAME OF DISABLED INDIVIDUAL: Dvo-gg? P{ \ \ (X
REMOVAL LOCATION OF DISABLED PARKING SPACE REQUESTED:
___3a\<\ to. e>gy\e^\q',oe
(Please print or type current sign location address.)
CHICAGO, ILLINOIS (ZIP COPE) fopklfe I PHONE NUMBERS 3> - H"^ © "<3£>^
REASON FOR REMOVAL: H-Q 1>-.D.___________
ILLINOIS VEHICLE LICENSE NUMBER:__
(W or V plate)
ILLINOIS DISABLED PLACARD NUMBER:
(Secretary of State)
CERTIFICATION: THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE;
FORMATION IS CUKKEC1 TO THE
r (Signature of Applicant)
FORWARD THIS COMPLETED APPLICATION TO YOUR ALDERMAN. APPLICANT: DO NOT WRITE BELOW THIS LINE
ALDERMANIC CERTIFICATION:
(Alderman Signature) (Ward) (Date)
AFTER APPROVAL, THIS APPLICATION IS TO BE FORWARDED TO COUNCIL SERVICES, BY THE ALDBRMAN, AT TUB TIME THE DISABLED SIGNS REMOVAL ORDINANCE IS INTRODUCED