HomeMy WebLinkAboutPermit Signage 2011-6-24
ZZ5 FIITH STREET. SPRINGFIELD, OR 9.7477 . PH:(541)726-3753 . FAX: (541)726-3689
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City Job Number Sf 1- 0/570
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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 installation above. If the' display is not
removed within the tirneline 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.
Signature ~t7~_ 6~rf . Date
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For Office Use
Job# Sf(-Ol 5"7 0
Receipt# 2ol( - - /76]
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Amount Collected
Shared Drive(T:)lBuilding FormsIBlimp]ennants_Balloons 7-08.doc
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www.ci.springfield.or.us
TRANSACTION RECEIPT
811-SPR2011-01570
1162 GATEWAY LOOP
CITY OF SPRINGFIELD
225 Fifth 8t
Springfield,OR 97477
541-726-3753
permitcenter@ci.springfield.or.us
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Credit Card michael schwartz
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RECEIPT NO: 2011001763 RECORD NO: 811-SPR2011-01570 DATE: 06/24/2011
rDESCRll1.TION" ~ ' '~',. -e.:t.ttTI,';",":C'O;'p'i ',,-'TIn' 2' Ac:ceUNT!C0DE'!X'" Yo}'", -".,":.ti^MOUNT.DUE' ~ ~ I
_ _ ,Admin.!.e."..I1 O'/~f appl~c~~e.!~)________ 224-000q~426605 1 8~00
224'00000-425602 80,00
821-00000-215500 100,00
100-00000-425605 4,00
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TOTAL DUE: 202,00
~,-,C_QII'!Mg&:r,S' ,..,.~ "- ,_ -,;;;;-:,,;';AMOUNT;PAID~ - "':", ; , ;~ I
refund to: sterling furniture 3194 202,00
gateway loop, springfield or 97477
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Technolo~y fe~,(5% of permit total)
TOTAL PAID:
202,00