251034 11/04/15 ,Coq.
v,
CITY OF CARMEL, INDIANA VENDOR: 369985
ONE CIVIC SQUARE VALERIE CLEVELAND CHECK AMOUNT: $**......75.00"
-, a CARMEL, INDIANA 46032 142 BELDEN DRIVE CHECK NUMBER: 251034
+,;,�roN.�` CARMEL IN 46032 CHECK DATE: 11/04/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
250 4350900 STORM WATER 75.00 OTHER CONT SERVICES
RESIDENTIAL COST-SHARE APPLICATION
f. CITY OF CARMEL STORM WATER USER FEE
4, RESIDENTIAL COST-SHARE APPLICATION
\�Orrn Watt/
APPLICATION TYPE: —Initial Application Installation Verification
APPLICANT NAME: APPLICANT PHONE NUMBER:
vQ�2c�e C12ve,���d 31�- 810 -IgS�3
APPLICANT EMAIL ADDRESS: APPLICANT MAILING ADDRESS:
ILA), �)bften iDnv2
CcVnQ_1 , IN 4U_e3'),
PROPERTY ADDRESS: W9, tY lve– , a- m I�, 14
I 0 D_
PROPERTY UTILITY ACCOUNT NUMBER: PROPERTY PARCEL NUMBER:
In-i H o l 4 s51 La i(1--- 10- -�rj--Oq--OD-o 13. CXD
COST-SHARE APPLYING FOR:
Rain Barrel _Rain Garden
Permeable Surface _Other approved BMP's
RIGHT OF ENTRY
Upon approval of this application,the applicant agrees to give the City of Carmel and authorized
representatives the right to enter the premises without hindrances,and inspect any-practice being
installed,or that has been installed,Eo receive a storm.rater utility credit. Denial of this right will result.in
the loss of the storm water credit. Applicant's Initials C.
APPLICANT SIGNATURE: DATE:
I
21
Submit application and attachments to: City of Carmel
Engineering Department
Attn: Department of Storm water Management
One Civic Square
Carmel, IN 46032
stormwoter@cormel.in.gov
Required attachments for the Residential Cost-share Incentive
INITIAL APPLICATION ATTACHMENTS INSTALLATION VERIFICATION ATTACHMENTS
39photos
Sketch of Site and Location of BMP(s) of Installation
_Photos of Site V.-seceipts
_Application Fee
For Department of Storm water Management Use
APPLICANT NAME:���� PROPERTY ADDRESS:
DATE RECEIVED: 91-2-1-1115-- RECEIVED BY:
TARGET AREA: APPROVED
COOL CREEK WATERSHEDLOST-SHARE AMOU T 75'
_REIMBURSEMENT SENT
DENIED(Reason)
STAFF SIGN E. DATE:
Z/ /5-
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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
Valerie Cleveland Purchase Order No.
142 Belden Drive Terms
Carmel, IN 46032 Date Due
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s) Amount
10/21/2015 0 Storm Water User Fee Residential Cost Share $ 75.00
Total $ 75.00
1 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.
Valerie Cleveland ALLOWED 20
142 Belden Drive IN SUM OF $
Carmel, IN 46032
$ 75.00
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT# I hereby certify that the attached invoice(s), or
0 0 250-4350900 $ 75.00 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
— 11/2/2015
Signa ure
City Engineer
Cost Distribution ledger classification if Title
claim paid motor vehicle highway fund