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City or ugene <br /> Planning & Development Department <br /> Building & Permit Services ` <br /> 99 W. 10th Avenue <br /> Eugene, OR 97401 <br /> Customer Information: Billing Information: <br /> Customer Name/Comparry Date <br /> 2 lZ~ ~ Q3 ~2l~32-~( <br /> <br /> Address Pwchase Order Number (non-City departmentrl <br /> City, State, Zip City Job Number or Account Code <br /> x' ~2 ~ ~,v ~ <br /> Customer Telephone Department to be !ed <br /> <br /> Contact Name <br /> Quantity Description of Service PIC Revenue Code Amount <br /> ~ ~ ~i2nf ~7~ ~o~l6N l0 3 /D D.o6 <br /> Total Due <br /> <br />