HomeMy WebLinkAboutPermit Signage 2011-5-9
ZZ5 FIrm STREET. SPRINGFIELD, OR 97477 . PH:(541)7Z6-3753 . FAX: (541)726-3689
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~ Date of Application 5
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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 ins taIl at ion above. lithe display is not
removed within the timeline specified, I will forfeit the $100.00 deposit. I also understand that this special
permit can be issued only once 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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Date
51<1/11
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For Office Use
Job# Sf/-oc::::> 77 ?
Receipt# 2011-00 70 7
Amount Collected
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Shared Drive(T:)IBuilding FormsfBlimp ]ennants _Balloons 7-08.doc
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www.ci.springfield.or.U5
TRANSACTION RECEIPT
811-SPR2011-00779
1712 MAIN ST 1
CITY OF SPRINGFIELD
225 Fifth 51
Springfield,OR 97477
541-726-3753
permitcenter@ci.springfield.or.U5
RECEIPT NO: 2011000907
lDESCRI~'nON .~. " ~..~""" ".
Admin fee (10% of applicable fees)
__..Blimp, 13.lIoon, Searchli9ht
.. . Blimp, ~alloo!:!:S."archl~9h.!Depos!t_ _... __._ _ ___.
__ T-"-0~0!og'y f.".e {5% of~err:nit tOlal)_____ _ __
RECORD NO: 811-SPR2011-00779
DATE: 05/09/2011
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ACCOUNLCODE
224-00000-426605
224-00000-425602
821-00000-215500
100-00000-425605
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TOTAL DUE:
AMQUNtDUE '
18.00
80.00
100.00
4.00
202.00
AMOUNT PAID.-
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LPAYMENT TYP.E'" PAYOE"CASHIER: DBOWlSBV
Credit Card ozone music
130188
CONiNlE:IiIS
refund deposit to: ozone music
1712 main st, springfield or 97477
TOTAL PAID:
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202.00
202.00