HomeMy WebLinkAbout243606 03/24/15 ,�''��` CITY OF CARMEL, INDIANA VENDOR: 366545
ONE CIVIC SQUARE OLD TOWN DESIGN GROUP CHECK AMOUNT: $*****3,225.91*
s. CARMEL, INDIANA 46032 1132 RANGELINE ROAD CHECK NUMBER: 243606
+y�._,_�. CARMEL IN 46032 CHECK DATE: 03/24/15
ETON C�•
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 3,225.91 OTHER EXPENSES
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*COILdPLETE&RETURN
REFUND REC�UES"r
TH[S FORM TO:
Building g&Code Services City of Carmel
fay Ph. 317 371-_444 Fax 317 571-2499
Bui[dina&Code Services
One Civic Square;
Carmel, IN 46032
PERMIT #(s): 14 I I o a 3 li I I baa a
Lot &Subdivision, or Address of Co/n�struction:
(If more than one address neeAs to be listed and will not fit, lease attach a printed list of all permits,with
their corresponding permit#.)
Please print or type the reason for the requested refund, and specific fee or fees
which are requested, in the lines below: h 1
Se>�ver)WoJe.►�-U-4 tIlj P0rm�� I'�IIGO�� l��dg P�rtm��#�`l MIC)
0ICQ i n�L 1ne'% 0CA hL,twne.y- c�
TOTAL EFLIND Asti U T REQUESTED:
3_la- Is_
Ap cant Signar Date
a�-�- 4l 0 L0 G ow n es i G r
Applicant Name—Printed Company Name( applicable)
APPLICANT ADDRESS:
113-. S . R0Lk1QeI1lr)e ROCAA . RUJf. 100 _
Street Address
Corm�1
city - ST zip
317- 605- 3 -7q Lo 317- ,�
Phone# Fax #
FOR OFFICE USE ONLY;
p Total amount for fees that ARE available for refund: �� 1
p Fees that are NOT available for refund: it Yo C,
p Refund approved by: Date:
p Date submitted for Payment: Amount Approved:
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(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.
}� I��'Payee
�� 1 D� S/�%Y► �JY��cvo Purchase Order No.
dA44)C� Z.ln7 ��, ut!� �llU Terms
LSM f �- `7 (OU3`L Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
-U 0L4' q®
Total
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
®� p0u B��Sa� ��� IN SUM OF $
113
C T�J `�4w3
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#!TITLE AMOUNT
DEPT.# 1 hereby certify that the attached invoice(s), or
X01 c50 A3 99v 39-b—9t 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
I 20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund