HomeMy WebLinkAboutPermit Signage 2011-6-7
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225 FIITH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689
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............ Date of Application
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City Job Number SI (-0 IsZ/
1/1'1 iMl~"J hojJ 3;;lio
170 ZZZO Tax Lot
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Address 3/7 C; 91?-rf0Lu j
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State
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Construction Contractors License #
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Expires
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 be issued only once per calendar year per development area. 1 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.
Signature ~~A . Date
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For Office Use
Job# SlI- 0/ s: z- r
Receipt# Zo II - / tf b 7
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Amount Collected
Shared Drive(f:}lBuilding FormsIBlimp_Pennants_Balloons 7...{l8.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-SPR2011-01321
1174 GATEWAY LOOP
perm itcenler@ci.springfietd.or.us
RECEIPT NO: 2011001467
[DESCRipTION ___ ~..
Admin fee (10%.?f applicable fees)
Blimp, Balloon, Searchlight
Blimp, Balloon, Searchlight Deposit
Technology fee (5% of permit total)
RECORD NO: 811-SPR2011-01321 DATE: 06/07/2011
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224-00000-426605 18.00
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224-00000-425602 80.00
821-00000-215500 100.00
100-00000-425605 4.00
TOTAL DUE: 202.00
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Credit Card
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. PAVOR. CASHIER, DBOWLSBY-
michael schwartz
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C-OM~EN:rS
refund deposit to: michael schwartz
3194 gateway loop, springfield or
97477
202.00
TOTAL PAID:
202.00