HomeMy WebLinkAboutApplication APPLICANT 12/10/2008
,City of Springfield
Development Services Department
225 Fifth Street
Springfield, OR 97477-
Time Extension Request
Certain Improvements &. Final Submittals
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Applicant Name:
Icompany:
IAdd~ess:
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IAPPlicant's Rep:':" ,-"
Icompany:
I~~d~re.~s:
I Property Owner:
I Company:
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Phone: 7"17 '8'70</
Fax: 7'-f 7 I?? 33
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Phone:
Fax:
Address:
ASSESSOR'S MAP NO: I 'J-D3-l5-,2~ ITAX LOT NOeS): /80 I
I Prope.rtv Address: ,I ,3 (.; ( "5 '" <;/r-C c-f-
ITe~ta~ive Case #: i\ C'- WI) ~ - C6CJ~' - S-~ g :2r:J-Wj ~ Obi L- (fe.J C?.vfj
I R~.ason for. ,If you are fillingin this form by hand, please attach your proposal .rescription to this ~PPlicatJon, '
Time ExtenSion: 'kft wu. /;'10" lhr..IJr.JvbrJC'.t!slo be!- M..Jfa/lccl
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Si natures: Please si nand rint our name and 'date in the' a riate box on the next a e.
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Date: I LJ / () j1)Q::,
IAPPlication Fee: $' '02-. \
ITechnical Fee: $0
Reviewed by: '1~
I Postaqe Fee: $0
TOTAL FEES:
0'2-I.G"\;)
PROJECT NUMBER:
I
-oco/4 I
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Date Received:
DEe 1 0 2008
Original Submittal
Revised 1/1/08 Molly Markarian
1 of 2
Signatures
The und~rsigned acknowledges that the information in this application is correct and accurate~
Applicant:
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Date:
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Signature
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Print
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If the applicant is not the owner, the owner hereby grants permission for the applicant to act in his/her behalf,
Owner:
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. Date:
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Signature
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Print
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Revised 1/1/08 Molly Markarian
2 of 2
225 Fifth Street
Springfield, Oregon 97477
541~726-3759 Phone
RECEIPT #:
.PAINQ~ELt:i ,';1.1,11", CO
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2200800000000001731
Job/Journal Number Description
SUB2008-00012 CTY Time Extend Cert Improv
Payments:
Type of Payment Paid By
Check
TOM WIRFS
-,ty of Springfield Official Receipt
tJevelopment Services Department
Public Works Department
Item Total:
Date: 12/10/2008
Check Number Authorization
Received By Batch Number Number How Received
Ij
691O
In Person
Payment Total:
2:57:26PM
Amount Due
321.00
$321.00
Amount Paid
$321.00
$321.00
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Date Received:
DEe 1 0 2008
Original Submittal
J 2/1 0/2008