Office of the City Clerk - Record #: O2011-1546

• Record #: O2011-1546
• Type: Ordinance
• Status: Passed
• Intro date: 3/9/2011
• Current Controlling Legislative Body: Committee on Traffic Control and Safety
• Final action: 4/13/2011
• Title: Handicapped Parking Permit No. 77393
• Sponsors: Cardenas, George A.
• Topic: PARKING - Handicapped
• Related files: SO2011-3566

Date	Journal Page Number	Action By	Action	Result
4/13/2011	115430	City Council	Passed	Pass
4/6/2011		Committee on Traffic Control and Safety	Recommended to Pass	Pass
3/9/2011	114172	City Council	Referred

 

APPLICATION FOR DISABLED PARKING SIGNS 77393 PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM

•>r\ application wiil not be considered complete unless: . _ _

• All lines of the application have been completed in full;       "if c> |0

• 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 tee 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 ot 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 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 o 1    I .o \ 3 M 1 C			2. State Identification Number I-1 i T.I I i T l u				3.  Drivers License Number ^ivi^t^i i\c\i-a\s\s
4. Applicant Last Name                                                               1 Ml | First Name S|A|L|£>| 4|D|o:                   ,   1   1           M^H^I*!*!   1   1   1   1   1 I
5. Home Address (pri STREET NUMBER I2H7I3I3	mar> dir. u).	' residence) STREET NAME iRp|   |S|T[   |4_[S|T|   \f\l_\°\o\<L\ \							ZIP CODE 6|o|C o
6. Address where sig STREET NUMBER 13-1713 13	ns w CXR OJ.	II be posted STREET NAME ^3!^|i>i \s\r\ i			. WARD NUMBER 1   1   1   1   1   I   1   I   1   1   I   I   M \*
7. Phone Numbers Home 7 17 1 ^Ts 12-13 7^ I o				0 | o	Business 1    1   T   1    1   T   i    ; 1
8. Current Permanent Disabled Placard Number				Registered to				Relationship to Applicant
9. Current License Plate Number				Registered to		City Sticker No.		Relationship to Applicant
10. Description of Medical Condition and Disability   ( ^ #0 LT) f? 1       ftf-flO?        f f            ff ^7 ^
Alternative Parking: Please note your application may be denied if you have alternative accessible off-stree1 parking options.
11. Is there off-street parking available at your primary residence        Q YES OfJO (i.e., garage, car port, driveway, etc.)?
12. If you answered Yes to question 11, please describe: . □ Garage;    □ Driveway;      □ Car Port;       □ Other k/~/ rT
13.1s your off-street parking accessible?                             / f □ Yes;         G^No. Please explain: /x//

14. Aflirmation: 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 than $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.

v Signature

Date

FOR OFFICE USEONLY

)$FEE J^PLACARD/PLATE I 'd 0*fr8-E2S-e<!.Z.

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