HomeMy WebLinkAboutPermit Signage 2011-5-3
22511ITH STREET. SPRINGI1ELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689
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Owner of Property
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Address ''S 0 '3;1,
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Address
Phone
City
State
Zip
Construction Contractors License #
Expires
Description (Zoof 6 LLC?:1,.J
Date ofInstallation Ji/4 ! I I
Date of Removal
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$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 furtber agree and understand that the above described display will be
removed witbin 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 $100.00 deposit if the display has been removed.
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Signature
Date
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Date of Application > '7. ((
For Office Use
Job#>li-C C> 73 2. Receipt# 2'0/1- gtf)
Issued By
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Amount Collected
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Shared Drive(T:)IBuilding FormslBlimp]ennants_BaIloons 7-08.doc
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www.ci.springfield.or.us
TRANSACTION RECEIPT
811-SPR2011-00732
3032 GA TEWA Y ST
CITY OF SPRINGFIELD
225 Fifth St
Springfield.OR 97477
541-726-3753
permitcenler@ci.springfield,or.us
RECORD NO: 811-SPR2011-00732 DATE: 05/03/2011
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224.00000.426605 16.00
224.00000-425602 80.00
821-00000-215500 100.00
100-00000-425605 4.00
TOTAL DUE: 202.00
UAYIV1EN:t;l)'e.E~RAYQB.u::li:5sHIE",DBowt!sBYJ.Y\,i:"',.~, : -: COMIVIENIS";~:'>G:.,>,X4i if'" . 'I "'V ~M()lJNT.pAID ,...
Credit Card jck restaurants inc refund deposit to: jck restaurants 202.00
003146 675 country club rd, eugene or
RECEIPT NO: 2011000660
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Admin lee (10% of applicable fees)
Blimp, Balloon, Searchlight
Blimp, Balloon, Searchlight Deposit
Technolo~y ree (5% of permit total)
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TOTAL PAID:
202.00