HomeMy WebLinkAbout229085 2/11/2014 CITY OF CARMEL, INDIANA VENDOR: 359989 Page 1 of 1
ONE CIVIC SQUARE D B KLAIN CHECK AMOUNT: $2,764.78
a CARMEL, INDIANA 46032 2159 GLEBE STREET#200
.o� CARMEL IN 46032 CHECK NUMBER: 229085
CHECK DATE: 2/11/2014
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 2 , 764 . 78 OTHER EXPENSES
"CONIPLETE& RETURN
REFUND REQUEST THIS FORM TO:
Building&Code Services City of Carmel
Ph. (317) 571.2444 Fax (317) 571-2499Building&z Code Services
One Civic Square;
����", Carmel, IN 46032
PERMIT #(S): q
Lot& Subdivision, or Address of Construction:
a) C,
(If more than one address needs to a listed and will not ht,please attach a printed list of all permits,with
their corresponding permit#,j
Please print or type the reason for the requested refund, and specific fee or fees
which are requested, in the lines below:
Deyelq2Lr UNa -
del iV�r
-T OD,,T�
Co tai,rx�
Da K� ,
TOTAL REFU D AMOUNT REQUESTED: ` �-7�4 7
2
�ag I DO 4
App icant Signa re Date
CW*UC-�-N) LLC
Applicant Name—Printed company Name(If applicable)
APPLICANT ADDRESS:
015q ole- )e Street Ste. gcxD
Street Address
Car i0e 1 NJ AQOo .
city 5T Zip
(312f4k- gC(4qcr) 131-7) ?410-cX)?o
Phone# Fax#
FOR OFFICE USE ONLY:
_ 1111 �1 )
p Total amount for fees that ARE available for refund: �D`I' �S JAN 2 9 2014
(r�0
1By—
p
Fees that are NOT available for refund:_ 44q, --
4 p Refund approved by: �a Date: I ail 14
p Date submitted for Payment: Amount Approved:
I
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.207(Rev.1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee L
}�L'{LAl (for j 1 tcte,T /en Purchase Order No.
o`Q0 Terms
C Aje/n C, L J 4(43 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4Z
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5-11-10-1.6.
20
Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
I� �l���J C'�`Tr►S�l"�f C-n��/t-�.��� IN SUM OF $
$ � r�
ON ACCOUNT OF APPROPRIATION FOR
AgJS
Board Members
PO#or INVOICE NO. ACCT#!TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
20 �w
fS.ignaurea
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund