CITY OF CHICAGO • BACP-^vl. sRAfi" OF 3R!VII_EGE pERM.~ . . ¦ ' •> / }~.L~ )
APPLICANT INFORMATION
LEGAL NAME OF EN'- ' CJfllPQ/? FoanS _
PERMIT MAILING AZOfEii gqi» U3 Rfh)J>ot-PU .Sf _
CITY: QJ|/.3fc-c> STATE jT/1 ZIP: ^ofiQ1?
CONTACT PERSON: f/rTCX? StfARuJAG TITLE: (S^rt-
PHONE^q-^Zfe-^^^T =AX J3(X-S~^-a^rfe E-MAIL: UtTE^ .flHftftuuAO
PROPERTY OWNER INFORMATION
NAME: Aj£g3 fYjft/OQ rO£*1T__
ADDRESS: 2(2. aJ ^V?a3£^/Y>DaJ SotfE- I A
CITY: C)4\LCib<=>_STATE: jTl__ZIP:
_
USE OF THE PUBLIC WAY
1. List the proposed or -e< s'.ing useis below, and complete the worksheet on page 3. Use only one application for all public way use type.
TYPE_ HOW MANY? BUILDING ADDRESS_
2. Please enclose one sketch of proposed use of the public way, which maps to scale the proposed use and its relationship to surrounding right-of-way. All measurements must be indicated.
3. All "No Fee" items require a $50 application fee. Please remit with application.
4. "No Fee" items are listed ''<-> the price list on page 6.
5. The prints should also accurately depict the location of the property line and public facilities (meters, light poles, sidewalks).
APPLICANT CERTIFICATION
I hereby certify that all statements made as part of the application, and the attachments herein, are true to the best of my knowledge and belief.
BY: 3 H,T£>J • ^///Hgu)aQ>_ TITLE: Pt& /s&U
F.E.I.N. or SOCIAL SECURITY NUMBER: J£2-29
ALDERMAN'S APPROVAL
As part of this application process, you are required to notify/obtain approval from the Alderman in whose ward your proposed use of the public way is located/1
ALDERMAN'S SIGNATURE:
DATE:
d use of the public way is locate
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WARD:
C H
I J4I T3 City of Chicago | Department of Business Affairs and Consumer Protection | Public Way Use Unit
" * " Rn<;inp<;<; A«ktanre> Center I ("irv Hall Room 800 I 171 North I aSallp Strppt I fhiraon Illinois fiflf
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