HomeMy WebLinkAboutApplication APPLICANT 2/8/2010
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,City of Springfield
Development Services Department
225 Fifth Street
Springfield, OR 97477
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SPRINGFIELD
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Time Extension Request
Certain Improvements & Final Submittals
Required. ProjecUnformation ' I"::"", ,r}' :' (Ap'plicant:'complete this ~e~tion)
A licant Name:
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Phone: .-
Address:
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A licant's Re
Phone:
Fax:
Address:
Owner:
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Com an
Address: 7
57 714 &~
ASSESSOR'S MAP NO:
TAX LOT NO S :
8, 5, 57'm- s1n~-t ;;., In ~,jJ 02-
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S Ct f3 200/-0 tP;2.3
17'-/78
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Tentative Case #:
Reason for If you are filling in this form by hand, please attach your proposal description to this application.
Time Extension: {Cct?lJr>'t/c .
-
Si natures: Please si our name and date in the a ro
. . . ~
~ Reviewed b :.]F'D-
lication Fee: $ 3 z. (
Technical Fee: $0
Posta e Fee: $0
TOTAL FEES: $ '3 "2 J
PROJECT NUMBER:P..e:.~.20bb-c?CO'b (
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Date Received:
FEB - 8 2010
Original Submittal
Revised 1/1/08 Molly Markarian
1 of Z
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Signatures
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The undersigned acknowledges that the information in this application is correct and accurate.
Applicant:
C;-\7~
Signatu e
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Date:
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Print
If the applicant is not the owner, the owner hereby grants permission for the applicant to act in his/her behalf.
Owner:
.s Curl t 0. S,
Signature
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, Date:
Print
Date Received:
FEB - 8 2010
Original Submittal
Revised 1/1/08 Molly Markarian
2 of 2