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City of Eugene '`-y T~ <br /> i' ~~t~~~ ate <br /> Planaing & Development Department it . i ~ C i ~ t ~-~'`t~~~ <br /> Building & Permit Services ~ " Job No. '-~Z--`1~--- <br /> 99 W. 10th Avemte ~ Contr No. <br /> <br /> Eugene, OR 97401 Ass ssment? Y or ~ <br /> I^app ove this for y e <br /> <br /> Customer Info ation: Billing Information: Q <br /> ;-~r pate ~ <br /> J® /T ~ <br /> J <br /> <br /> Customer NamdCompany Da!< , <br /> Purchase Or r Number (non-City departments) <br /> C! State, Z! ClryJob Nu~mjber~or,lecount Cods <br /> Customer T Iephone Department to be B!!led <br /> Contact Nano <br /> Qualntity ~-y~ ~a, Description o~f-cSe~rvr ice PIC Revenue Code Amount <br /> I ~~-t~s~~ l ~vC..~ ~l!-4ZZ1- ~S fejD ~~lt~ <br /> ~l ~ ~1_~~.j- zISS~(a ~ e t~~ <br /> r ~ ~ ~s~ ~ ~ ~ - ~ ~ 2~~ ~ <br /> _ . - _ ~ - _ - ~ ~ I , ~ ~ Total Due <br /> <br />