HomeMy WebLinkAboutApplication APPLICANT 11/19/2010
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'city of Springfield
Development Services Department
225 Fifth Street
Springfield, OR 97477
Historical Review Application
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(Applicant: check one)
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Application Type
Historical Review Tel - Minor Alterations' Sites or Structures:
Historical Review T e II - Ma"or Alterations' Sites or Structures:
Historical Review T e III:
Addition of a Site or Structure to the Historic landmark Invento
Removal of a Site or Structure from the Historic landmark Invento
Demolition of Historic land Mark Structures
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Phone: J"l-11-9tfl- 69f'f
Fax:
Address:
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A Iicant's Re ..
Phone:
Com an :
Address:
Fax:
Com an
Address:
Phone:
Fax:
ASSESSOR'S MAP NO: 1"1- ~3 15 '2 ~ TAX lOT NO S
Address: , 0 "1- D S+r~ f 1;
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Description of If you are filling in this form by hand, please attach your proposal dejtriptlon to this applicati~ry _
Proposal: . a.rJ.J,:rl.J 0-. 6' Y J)" hrtJ+- 6",...".J ~ /V"rt1. J/~
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Associated A Iications:
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Case No.: 1\ () - <SD \ 1....- Date: / /
A Iication Fee: bO Technical Fee:
3
TOTAL FEES:
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PROJECT NUMBER:
Revised 1.16.09ddk
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NOV 1 9 2mOf 7
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Original Submittal
Signatures
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An application without the Owner's original signature will not be accepted.
Applicant:
Owner:
Revised 1.16.09ddk
The undersigned acknowledges that the information in this application is correct and accurate.
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Signature
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Print 1
Date:
If the applicant is not the ner, the owner hereby grants permission for the applicant to act in his/her behalf.
Signature
Print
Date:
Date Received:
NQV 1 9 2010
OriJinai Submittal
2 of 7
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