250835 10/21/15 pr C�qM
J�!�� �� CITY OF CARMEL, INDIANA VENDOR: 369421
`` ONE CIVIC SQUARE DAVID RUTTI CHECK AMOUNT: $********30.00*
s CARMEL INDIANA 46032 12254 RIDGESIDE RD CHECK NUMBER: 250835
::
+��ipN�` INDPLS IN 46256 CHECK DATE: 10/21/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1192 4357002 360725-1 30.00 EXTERNAL TRAINING FEE
APPLICATION Cert. No. S 309 Y7'6
for
CERTIFICATES REQUIRING
MULTIPLE EXAMINATIONS
NTER�IATIQNAL This application is not required for Fire Inspector ll.
CODE COUNCIL!
To receive a certification that requires the completion of more than one examination, complete this application and
submit to ICC at the address at the bottom of this page with appropriate fee payment. Enclose$30.00 for each certi-
fication category. Master Code Professional, Certified Building Official, and Certified Fire Marshal certifications are
complimentary.
Please do not submit this apulication prior to receiving your certificate and/or wallet card for the qualifying
examinations.
I have successfully completed the required examinations and request certification for:
❑ B5 Building Inspector JR5 Residential Combination Inspector ❑ F6 Certified Fire Code Official
❑ E5 Electrical Inspector ❑ C5 Commercial Combination Inspector ❑ M6 Certified Mech Code Official.
❑ M5 Mechanical Inspector - ❑ C8 Combination Inspector ❑ P6 Certified-Plbg Code Official
❑ P5 Plumbing Inspector ❑ C3 Combination Plans Examiner ❑ H6 Cert Housing Code Official
❑ B6 Certified Building Code Official ❑ CB Certified Building Official" ❑ E6 Cert Electrical Code Official
❑ MP Master Code Professional" ❑ MI Master of Special Inspection ❑ G8 Energy Code Specialist
❑ FM Certified Fire Marshal" ❑T6 Permit Specialist.
$30 fee does not apply to MCP,CBO,or CFM certification categories
Certificate and Mailing Information
L . �
Name Please print your name as you desire it to appear on each certificate.
Mailing Address
t,..AA�0t t_Ski b -S
City State ZIP
I Ltylo I., beA r,_e,+
Contact Phone mb r EmaiAddress
c
Signature Date
Note: 45-70 days is required for verification of records prior to issuance of requested certificates.
Payment Information .
Total number of certification categories: f X $30 per category = �� total to enclose.
Method of Payment
`heck or money order—payable to: ICC
11 Visa ❑ MasterCard ❑American Express ❑ Discover
Credit Card No. / / / Expires /
Signature of Cardholder Date
Name as it Appears on Credit Card
Mail completed application with required fee payment to:
International Code Council
Certification &Testing Department
900 Montclair Road
Birmingham, AL 35213
OFFICE USE ONLY
Candidate ID: Requirements met: Date processed: Initials:
25-3
DAVID L.RUTI7 o9-11. aao 344
PHYLLIS A.RUM
12254 RIDGESIDE RD. qq
INDIANAPOLIS,IN 46256-9401 DATE tG
PAYSOTHE �
ORDEROF •_ un�Y�~^ L.C.} �j
sem'— DOUM 8 scermn
CHASE
Morgan Chase Bank,N.A.
wuwv.Chase.com
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MEMO C1M •+h at tiN �4V
VOUCHER NO. WARRANT NO.
ALLOWED 20
David Rutti
IN SUM OF$
C/O One Civic Square
Carmel, IN 46032
$30.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel DOCS
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1192 43-570.02 $30.00
I hereby certify that the attached invoice(s), or
I I I
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
Thursday, Oct ber 15, 2015
Directo
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Prescribed by State Board of Accounts City Form No.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
10/15/15 $30.00
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