Clear Form
City of Emeryville
INCORPORATED 1896
1333 Park Avenue. Emeryville, CA 94608-3517
+ (510) 596-4300 | f (510) 596-4389
Application for an ADA Blue Disabled Parking Zone
APPLICANT INFORMATION
Full Name: Date:
Idowu Koyejo 05/07/2025
Business Name (if applicable):
TEME SALON
Business / Mailing Address:
4515 Hubbard St. C-126 Emeryville CA 94608
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):
4515 Hubbard St. C-#126 Emeryville CA. 94608
In front of #126 #|26
In front of TEME SALON on Hubbard
Reason for Request:
Not enough close parking - I am treated weekly for chronic medical issues. Having the blue parking close to my business/ living space is needed within the area.
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 guaranteed.
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? 4 Yes • No Can a copy of a current DMV-Issued Vehicle Registration form be V 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.
Idowu Koyejo 4e1/2025
Name Date
CITY OF EMERYVILLE
City Manager's Office
Please return the completed application and required documents to: Attn: ADA Administrator 1333 Park Avenue
Emeryville, CA 94608
REMOVE FROM MIRROR BEFORE DRIVING VEHICLE
CALIFORNIA
WARNING: The illegal use of a disabled parking placarc
could result in a maximum fine of $4,200."
DISABLED PERSON PARKING PLACARD
EXPIRES
JUNE 30
2027
If found or if the placard holder is deceased, return to:
DMV
PO Box 942869 M/S C271
Sacramento, CA 94269-0001
California Evidence of Liability Insurance
NAIC Number: 10192
dowu Koyejo Policy Number: 985492789 Expiration Date: 08/28/2025 Effective Date: 02/28/2025 Insurer: Progressive Select Ins Co 1-800-776-4737 PO Box 31260 Tampa, FL 33631
Valued Customer Since 2024 Named Insured(s):
Idowu Koyejo
Model
Year Make Avalon
2015 Toyota Is 250
2015 Lexus
This policy complies with Section 16056 or 16500.5 of the California Form A022 CA (08/24)
Vehicle Code.
IF YOU'RE IN AN ACCIDENT Evidence of financial responsibility shall at all times be carried in the
1. Remain at the scene. Don't admit fault.
2. Find a safe location, call the police, and exchange driver information. vehice.
Insurance information has already been submitted directly to the DMV electronically, submit this document to DMV only if specifically requested
3. Call Progressive right away.
TO REPORT A CLAIM by DMV.
Call 1-800-274-4499 or go to claims.progressive.com.
! DEPARTMENT OF MOTOR VEHICLES PLACARD NUMBER:
DISABLED PERSON EXPIRES: 06/30/2025
PLACARD IDENTIFICATION DATE ISSUED: 03/01/2023
CARD/RECEIFT
This identification card or facsimile copy is to be carried by the placard owner. Present it to any peace officer upon demand. Immediately notify DMV by mail of any change of address. When parking, hang the placard from the rear view mirror, remove it from the mirror when driving.
When your placard is properly displayed,
TYPE: N1 TV: 92 you may park in or on:
Co: 01 • Disabled person parking spaces (blue zones)
DOB:
• Street metered zones without paying.
ISSUED TO * Green zones without restrictions to time limits. * Streets where preferential parking privileges are given to KOVEJO IDGWU 0 7 residents and merchants.
You may not park in or on:
* Red, Yellow, White or Tow Away: les.
• Crosshatch marked spaces next to disabled person
parking spaces.
it is considered moled owne Jisuse to'
* Display a placard unless the disabled owne is being
transported.
Purchase of fuel * Display a placard which has leen canceller for revoked. (Business & Professons Code 13660): * Loan your placard to anyone including fam Ally members. • State law requires service flations to refuel a and can disabled person's velicle a sell-service rates, result in cancellation or revocation of the pl Misuse is a misdemeanor (section 4461VC), acard, loss except self-se. aacilities with only one cashier.
of parking privileges, and/or fines.
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