HomeMy WebLinkAboutPermit Signage 2011-5-25 (2)
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CITY OF SPRINGFIELD, OREGON
225 F1mUTREET . SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689
SPRINGFIELD
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City Job Number
>P.LLc>((~oJI g3
'51$$ I\'\/l..it-J $'-t,,~
{7DZ 33'11{
Tax Lot
Job Location
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Assessors Map
Owner of Property ~I",\ '-"'-~ ""~ (f:,..\ \-."-.,--\.~ ,,~
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City
State
Zip
Contractorllnstaller
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OWN t:A.
Address
Phone
City
State
Zip
Construction Contractors License #
Expires
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Date ofInstallation 5 IZlh-" II
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Description
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Date of Removal ~-1-.z:ou
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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
infonnation 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 $ I 00.00 deposit. I also understand that this special
pennit can be issued only once'perrnlendar year per development area, I also agree to call the inspection line at
726-3769 by the end of~~aY to request an inspection to verifY the removal of the display. This inspection
will begin the process to return the $100.00 de it if the display has been removed,
Date ~L'->-Lt7I/
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For Office Use
Date of Application
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Receipt# ~
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Job# 511~o If i '3
Issued By
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Amount Collected
Shared Drive(T:)lBuilding FonnsIBlimp]ennants _Balloons 7-08,doc
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TRANSACTION RECEIPT
CITY OF SPRINGFIELD
225 Fifth 51
Springfield,OR 97477
541-726-3753
www.ci.springfield.or.us
811-SPR2011-01183
5755 MAIN ST
permitcenter@cLspringfield.or.us
RECEIPT NO: 2011001323
[OESCRIP.TION ' .
Admin fee (10% of applicable fees)
Blimp, Balloon, Searchlight
Blimp, Balloon. Searchlight Deposit
Technology fee (5% of permit total)
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RECORD NO: 811-SPR2011-01183 DATE: OS/26/2011
,';>',Ji:~:, 'Ac6oUNT~CODE' ," AMOUNT.DUE
224-00000-426605 18.00
224-00000-425602 80.00
821-00000-215500 100.00
100-00000-425605 4,00
TOTAL DUE: 202.00
'"AMOUNT PAID - ,
202.00
LP~YI'IIEtlT1),J~J:
Check
919
. '" . PAvbR . CASHIER:.O'BOWLsBY"
albertsons
. COJ'IIJ'JIE!ilTS-
refund to: albertsons 5755 main
street, springfield or 97478
TOTAL PAID:
202.00