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city o uge°e i ?2outs Gate ~ $ S + . <br /> Pianuing & Development Department I Z~o. ~~r ~d/3~ ~ •~j o ~~y ' <br /> Building & Permit Services Job No. .fit- Z b~ ~t <br /> 99 W. 10th Avenue Contr No. ~/2 5! ~ cam) I ~ e <br /> Eugene, OIt 97401 Assessment? YES or U <br /> ap eve tgis for <br /> Customer Information: ~ S;gna Date ~ - Billing Information: <br /> Customer N Company Date ' <br /> <br /> Addr~ Purchase Order <br /> Nummber rtmenls) <br /> City, Smtt, Z+P 6 Number or <br /> ~ ~ ~ <br /> Custo~jm~e/r /T~dtphoQnt/Q , ~ Department to be Bf!!ed <br /> Contact Name <br /> Quantity Description of Service PIC Revenue Code Amount <br /> f ~~-D Sl~7tiI ~a0'Q C - ~ 5 4 --s s-~ ~ z3 ~Ql~ <br /> ~ l /U ~ ~95~-~0 - tsl ~ L I ~ ` 0 <br /> ~ <br /> Total Due <br /> <br />