till FEB 2 fin 8
January 19, 2011
ALDERMAN BERNARD STONE WARD 50
121 N LA SALLE STREET - 203 CHICAGO, IL 60602
Dear ALDERMAN STONE:
Please see the attached application for disabled parking signs. The applicant is requesting a restricted parking space within your ward.
The Department of Revenue will conduct a parking study and review the application for compliance with Chapter 9-64-50 of the Municipal Code of Chicago. The Department will make its recommendation to you within thirty (30) days of the receipt of the application fee.
Should you have any questions or require additional information, please contact our office at 312.742.7434.
Deputy Director Department of Revenue
Enclosure: Disabled Signs Application
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
74672
An application will not be considered complete unless:
All lines of 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.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 ihe time of application.
Completed application forms may be returned to: the office of your alderman, any City of Chicago Department of Revenue facility, or via mail at P.O. Box 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 MO__DAY _ YEAR D| C\ L & \ £ \Q |
2. State Identification Number ■ j 3. Drivers License Number n&\tidM<te\i \m\dr.u\& \&\o\o\7\<^ti-w\£ |
4. Applicant Last Name aM£\rZ\p\£U\ I I I I I I I I I |
Ml 5 |
First Name bW\$\E\L\ 1 1 1 1 1 1 |
5. Home Address (pr STREET NUMBER G\Q\'^\l4 I |
mary DIR. /V |
residence) STREET NAME II zlp CODE C>\i-\\c\ \I I I I. I I I I I I I I l^l^k/Lc |
6. Address where sig STREET NUMBER &\h \ ~kW\ |
ns w DIR. |
II be posted STREET NAME o\4\h\i \&\y\ I I |
WARD NUMBER M i i i I i i i i I 1 FVfi |
7. Phone Numbers Home R T/ol9l /T<?l£ |
|
Business |
8. Current Permanent Disabled Placard Number |
Registered to H/Of^l ^rX/r^l G>.Lr**e* |
Relationship to Applicant n carter |
|
|
|
9. Current License Plate Number |
Registered to |
City Sticker No. |
Relationship to Applicant |
|
|
|
|
10. Description of Medical Condition and Disability [)iCcb;' /■/><" ■ aiiJ U/«oU(? -hey t-^-c^f k |
Alternative Parking: Please note your application may be denied if you have alternative accessible off-street parking options. |
11. Is there off-street parking available at your primary residence □ YES jJ^NO (i.e., garage, car port, driveway, etc.)? |
12. If you answered Yes to question 11, please describe: □ Garage; □ Driveway: □ Car Port; □ Other: |
13. Is your off-street parking accessible? 'iu Yes: I?7 Mo. Please explain: |
|
|
|
|
|
|
|
|
|
14. Affirmation: I hereby affirm that the above information is true and correct. If the City of Chicago Department of Revenue determines that the applicant has falsely represented one or more of the. above conditions, the applicant shall be subject to a fine of not less than £100 but no more irian $500, and the; application shall be denied. I also understand that it is my responsibility to notify the Department of Revenue of any changes in the information provided.
Signature,
Date
FOR OFFICE U9£^ONLY
□ PLACARD/PLATE
□ RESIDENCY □ COMPLETE h1r\oo