HomeMy WebLinkAboutPermit Signage 2010-10-1
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ZZ5 FIfTH STREET. SPRINGFIEW, OR 97477 . PH:(54I)726-3753 . FAX: (541)726-3689 ~~~~~~;".:~ ~
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City Job Number ;;;:.,. t.>'
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Assessors Map I 7 0:5 ZS4 Z.
Job Location
OD70C
Tax Lot
Owner of Property (A)~/1/,[) Y Mt-FA/
Address 2.l'j ~/ 3 OL (,lJ'JPTr..
City ~ pf?J:A1..r-.-Z:FLT) State
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2--i ~ 7
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Phone
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Zip
Contractor/Installer
Address
Phone
City
State
Zip
Construction Contractors License #
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Description
Expires
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Date of Installation
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)(3 -1- /0)
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Date of Removal
$202.00 including $100.00 Deposit and applicable fees.
By signature, I state and agree that I have carefully completed this application and hereby certifY that all
information herein is true and correct. I further agree and understand that the above described display will be
removed within fourteen (14) days from the date listed as the date of installation above, If the display is not
removed within the timeline specified, I will forfeit the $100.00 deposit. I also understand that this special
permit can only be issued twice per calendar year per development area.' I also agree to call the inspection line at
726-3769 by the end of the 14th day to request an inspection to verifY the removal of the display. This inspection
will begin the process to return the $100.0 eposit ifthe display has been removed,
Signatu
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Date of Application
10-1-10
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Job# SID ~ 00 '{Z'1
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Receipt# 20(0 .
9Z-
Issued By
Amount Collected
Shared Drive(T:)!BuiJding Fonns!Blimp _Pennants_Balloons 7-OB.doc
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www.ci.springfield.or.us
TRANSACTION RECEIPT
811-SPR2010-00423
2043 OLYMPIC ST
CITY OF SPRINGFIELD
225 Fifth St
Springfield, OR 97477
541-726-3753
permitcenter@ci.springfield,or.us
RECEIPT NO: 2010000469 RECORD NO: 811-SPR2010-00423 DATE: 10/04/2010
[DE~CRIJ'"TLQtf':l~~' r:'"~;;;'~Y;:?~22";~"""i:~%;!c,,,'. ,::':".;;;i"':~~'~ .gQ.c.c:>.UN."Tlc.l:!ol; . ::.;. 'i((:?';AMQI.tr:!;r OJ;!.E' '.
Blimp. Balloon. Searchlight 224:00000-425602 $80.00
Technology fee (5% of permit total) 100-00000-425605 $4.00
Admin fee (10% of 'Pplicable fees) 224-00000-426605 $8.00
TOTAL DUE: $92.00
!.f1AYMENTTYf1Ee~J",oAYO R', ,:'tC'ASHIER: DBOwLSBY"-"i',.l,'COMMEN' TS,4','},/"f',;_.f.-;"';' c. 'A"."M'.O_UNT.':'A,IP" '''...... ,.,,',.1
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Credit Card
214055
brian proett
$92,00
$92,00