APPLICATION pOR DISABLED PARKING SIGNS PLEASE READ THIS FOLLOWIf IG CAREFULLY BEFORE COMPLETING TrIE FORM
77403
An application will not T>e crj^isidered complete unless; i ; nnii_N*_t
All linfis nf the application have hefin rompleled in fjll. TjJfAjJ' fl- I
A check or money order lor $70,00 made payable X (he City ol Chi; ;ago is submitted as payment of the application fee: Please note: The application fee shall be waived br any person hoi |mg a valid, current disabled veterans; plate
Disability must be permanent as evidenced by a copy ol your valid iisabled placard and/wr current vehicle registration submitted al tho timo of application;
Proof of residency, in the form of a copy of your di vprs license, stat j identification, or utility bills are submitted at Ihe time of application
Completed application forms may be returned to the olf ce of your alde: man. any City of Chicago Department of Revenue facility, or via mail at PO. Box 803100. Chicago, IL BOtjE0-3100, ATTN, disabled Permitting Section. A $25.00 mainlent-mw fee will be billed to you annually. Should you have qu-= s lions or concerns, please call our permit processing division at 312-744-PARK (7275).
_G>[c |V4|o |Y ] 0| 5| | C | o, | 1 | A I ft j 1' [ o I ^
4| *4
1 Date ol Birth
MO _ OAV
2. Stale Identification dumber
A Applicnnt I nsl Name
5 Homo Addioss (piim-iiy residence-)
r:Tnrr.T Nuwinn
| Oil I
stiiect NAME
H I 0k I r
3 Drivers License Number.
Pl^MsTsM°lsTH*niM
First Nnmo
«mh;i<\i i i i i i i
6. Address where signs will be posted
RTnrr-T Niiwnrn om ttmcct name ,
* l.1* I Al "I I I s|m|» |r i s Mil . I -ill
7. Phone Nuinbcis Homo
* I 1 I * I M I
8 Current Permanent Disabled Placard Number feP> \ 'A^X ____
M Currcnl I iccnst! Plait! Numbnr
HA
1*
I _,ir cji.iul
j> j O I (oT
-WAMU NUMULI1
I U \T-\
Bu.siiioss
1
NAgister, d to
Cfl»U«-r0ri it gislnrect to Dity Slicker No
v><-.- .cl-C f usiHl
Rc<l.wli(in<iliip l<> Appli'.-^iil WCtScI (-
10 Uescnption nf Modical Condition and Disability
Alternative Parking Please note your application may be deni *l il you have alternative ncxoMibic olf sdeel packing options
11, Is ihc-io oll-sttcoi paikiny available at your piirnary tcsidcii. (i.e . garage car port, driveway etc.)?
□ YES *T NO
U II you answered Yes lo question 11. pleasti destribi.v J Ga'sgo; Li Onvoway; LI Car Pom: LI Othci
Kl lr your off-flrcrl parking ntxcsaiblo? □ Yes. 'S No. Please explain
-Vo
yv*o»n
Mc^f
Ii Affirmation I hereby affirm that the above information is idm and correct. III je Cily ol Chicago Drpnrlmrnt ol Rcvcnuo determines llial Ihe applicant lias falsely represented one ur morn ol ih« 'it.ivi! conditions, it" s applicani shall be subjpcl to a lino ol not less- ihan $100 but no more lhamSOOO, and the application shell be dcis i l also undetsla Id Hint it is iny responsibility to notify the Department ol Revenue of any clyfnyes m llie ifilnrmaty>n provulrxj., ^
Signalurt!
Date
2L" ^ ' //
FOR OFFICE USE ONLY
□ FFF
'J PI ACARD/r ATP .1 RF SIOrNCY 'I COMPI FTP
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FEB-14-2011 00:53 From:12TH WARD ALDERMAN 7735238440
To:46B24
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1 APPLICATION pOR DISABLED PARKING SIGNS PLEASE READ THIS FOLLOWIf IG CAREFULLY BEFORE COMPLETING TrIE FORM 77403 An application will not T>e crj^isidered complete unless; i ; nnii_N*_t All linfis nf the application have hefin rompleled in fjll. TjJfAjJ' fl- I A check or money order lor $70,00 made payable X (he City ol Chi; ;ago is submitted as payment of the application fee: Please note: The application fee shall be waived br any person hoi |mg a valid, current disabled veterans; plate Disability must be permanent as evidenced by a copy ol your valid iisabled placard and/wr current vehicle registration submitted al tho timo of application; Proof of residency, in the form of a copy of your di vprs license, stat j identification, or utility bills are submitted at Ihe time of application Completed application forms may be returned to the olf ce of your alde: man. any City of Chicago Department of Revenue facility, or via mail at PO. Box 803100. Chicago, IL BOtjE0-3100, ATTN, disabled Permitting Section. A $25.00 mainlent-mw fee will be billed to you annually. Should you have qu-= s lions or concerns, please call our permit processing division at 312-744-PARK (7275). _G>[c |V4|o |Y ] 0| 5| | C | o, | 1 | A I ft j 1' [ o I ^ 4| *4 1 Date ol Birth MO _ OAV 2. Stale Identification dumber A Applicnnt I nsl Name 5 Homo Addioss (piim-iiy residence-) r:Tnrr.T Nuwinn | Oil I stiiect NAME H I 0k I r 3 Drivers License Number. Pl^MsTsM°lsTH*niM First Nnmo «mh;i<\i i i i i i i 6. Address where signs will be posted RTnrr-T Niiwnrn om ttmcct name , * l.1* I Al "I I I s|m|» |r i s Mil . I -ill 7. Phone Nuinbcis Homo * I 1 I * I M I 8 Current Permanent Disabled Placard Number feP> \ 'A^X ____ M Currcnl I iccnst! Plait! Numbnr HA 1* I _,ir cji.iul j> j O I (oT -WAMU NUMULI1 I U \T-\ Bu.siiioss 1 NAgister, d to Cfl»U«-r0ri it gislnrect to Dity Slicker No v><-.- .cl-C f usiHl Rc<l.wli(in<iliip l<> Appli'.-^iil WCtScI (- 10 Uescnption nf Modical Condition and Disability Alternative Parking Please note your application may be deni *l il you have alternative ncxoMibic olf sdeel packing options 11, Is ihc-io oll-sttcoi paikiny available at your piirnary tcsidcii. (i.e . garage car port, driveway etc.)? □ YES *T NO U II you answered Yes lo question 11. pleasti destribi.v J Ga'sgo; Li Onvoway; LI Car Pom: LI Othci Kl lr your off-flrcrl parking ntxcsaiblo? □ Yes. 'S No. Please explain -Vo yv*o»n Mc^f Ii Affirmation I hereby affirm that the above information is idm and correct. III je Cily ol Chicago Drpnrlmrnt ol Rcvcnuo determines llial Ihe applicant lias falsely represented one ur morn ol ih« 'it.ivi! conditions, it" s applicani shall be subjpcl to a lino ol not less- ihan $100 but no more lhamSOOO, and the application shell be dcis i l also undetsla Id Hint it is iny responsibility to notify the Department ol Revenue of any clyfnyes m llie ifilnrmaty>n provulrxj., ^ Signalurt! Date 2L" ^ ' // FOR OFFICE USE ONLY □ FFF 'J PI ACARD/r ATP .1 RF SIOrNCY 'I COMPI FTP b589b:°l 0bb8£ES£:_._. NbWd3Q"l« QdbM H12I:woj_ £c;:0_, TT02-bT-a3d FEB-14-2011 00:53 From:12TH WARD ALDERMAN 7735238440 To:46B24 P.2'3 0 ■■■■'ij 6070V II 00( HIO MOBJOllJ-SOAOMjg V| IVN Q L-O£*0t ""i U -Sl-01 95-5101 w f»i8V SOfrS EfrCO " h> 3SN33n S;tt3AI80 (< HTM rA|nr -eny -Idas"IPO "AON "9^01 171!6 8 ZZ 9 |
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FEB-14-2011 00:53 From:12TH WARD ALDERMAN 7735238440
To:46824
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