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City of Eugene ' <br /> Planning & Development Department <br /> Building & Permit Services <br /> 99 W. 10th Avenue <br /> Eugene, OR 97401 <br /> Customer Information: Billing Information: <br /> cost , amc/ Darr <br /> <br /> 2g~cj G'~~rt~ ~revu.~e. <br /> Address Purchase Order Number (non-Cary departmanu) <br /> ~z~Z <br /> Clry, Swte, Z!p ~ ~ ~ ~ C1ry Job Number or Accounl Coda <br /> < < <br /> Customer Telephone ~ ~ r ~ ~ ~ (t ,r Deparanenl ro ba Bl/kd <br /> A ~ ~ .G v~ 1 <br /> Con t Name ~ - : <br /> f <br /> Quantity ~ ~ ~ PIC Revenue Code Amount <br /> r ~ 5 ~i3Z3 <br /> r <br /> S~o~" <br /> Total Due <br /> <br />