Clear Form
City of Emeryville
INCORPORATED 1896
1333 Park Avenue. Emeryville, CA 94608-3517
+ (510) 596-4300 | 5(510) 596-4389
Application for an ADA Blue Disabled Parking Zone
APPLICANT INFORMATION
Full Name: Date:
harks Hurbert 12/20/21
Business Name (if applicable):
Business Phone: Home Phone: Cell Phone:
Email Address:
• I require language translation assistance (please specify which language): * Street Address / Intersection / Location of Proposed Parking Zone (please be as specific as possible):
1048 455 57.
Reason for Request:
Remove handicap/ blue curb
RESIDENT APPLICANTS ONLY
Proof of Emeryville Residency
Residential applicants must provide one of the following proofs of residency with the application:
1. Utility Bill
2. State or Federal Issued Picture Identification
3. Rental or Lease Agreement
4 Staff will make every possible effort to provide the applicant with language translation assistance services; however, language translation assistance cannot be quaranteed
City of Emeryville | Application for an ADA Blue Disabled Parking Zone Proof of Disability and Possession of DMV-Issued Disabled Placard Residential applicants must have a valid State-issued Disabled Plate or Placard. Proof can be provided by submitting a copy of supporting documentation issues by the DMV.
Can a copy of a DMV-Issued Disabled Placard be provided? • Yes • No Can a copy of a current DMV-Issued Vehicle Registration form be • Yes • No provided?
UNDERSTANDING OF ADA BLUE DISABLED PARKING ZONE POLICY AND USE
AGREEMENT
I have read and understand the Disabled Blue Zone Parking Policy, and to the best of my knowledge, my request meets ALL the installation criteria, requirements, and conditions presented. I agree to meet with staff from the City to review the installation request, and if approved, understand that I have a duty to inform the City if the space is no longer required. I also understand that, if approved, this will not be a private space for my residents or business, and that it must be made available to other vehicles that display a disabled placard on a first come, first served basis.
Charles Hurbert 12/20/21
Signature Name Date
CITY OF EMERYVILLE
City Manager's Office
Please return the completed application and required documents to: Attr: ADA Administrator 1333 Park Avenue
Emeryville, CA 94608
ENERGY STATEMENT Account No:
Statement Date: 11/19/2021
www.pge.com/MyEnergy Due Date: 12/10/2021
Service For: Your Account Summary
CHARLES J HURBERT & CAROLINE Amount Due on Previous Statement BELENO Payments) Received Since Last Statement
1048 45TH ST
Outstanding Credit Balance
EMERYVILLE, CA 94608
Current PG&E Electric Delivery Charges
East Bay Community Energy Electric Generation Charges
Questions about your bill? Current Gas Charges
Monday-Friday 7 a.m.-9 p.m.
Saturday 8 a.m.-6 p.m CREDIT BALANCE - NO PAYMENT
Phone: 1-800-743-5000
DUE
www.pge.com/MyEnergy
Ways To Pay
www.pge.com/waystopay
Monthly Billing History Daily Usage Comparison
1 Year Last Current
Ago Period Period
2021 9/22 10/21 11/19 2021-
Electric Gas
Visit www.pge.com/MyEnergy for a detailed bill comparison Important Messages
The winter Tier 1 (baseline) season begins on November 1. Your baseline quantity will vary during the winter months Your total Tier 1 quantities were calculated using your daily winter baseline allowance starting November 1 and your daily summer baseline allowance for any days in your billing period before November 1.
No payment is due. Please retain for your records. Thank you. 99901815514562800000054400000000000
Account Number: Total Amount Due:
Pr&E No Payment Due
710180064441 01 AV 0.42 384 702 8
PG&E
BOX 997300
CHARLES J HURBERT & CAROLINE BELENO
SACRAMENTO, CA 95899-7300
Printed with Water Based inks on SFI certified paper