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CITY OF CARMEL, INDIANA VENDOR: 369080 CHECKAMOUNT: S•"'*'""'50.00"
ONE CIVIC SQUARE HEATHER AND GARRET MUDD
CARMEL, INDIANA 46032 330 W 106TH STCHECK NUMBER: 306118
INDIANAPOLIS IN 46290 CHECK DATE: 12/12/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
250 4350900 50.00 OTHER CONT SERVICES
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RESIDENTIAL COST-SHARE APPLICATION
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CITY OF CARMEL STORM WATER USER FEE
RESIDENTIAL COST-SHARE APPLICATION40 i��eiirr
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APPLICATION TYPE: _Initial Application ox Installation Verification
APPLICANT NAME: APPLICANT PHONE NUMBER:
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APPLICANT EMAIL ADDRESS: APPLICANT MAILING ADDRESS:
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PROPERTY ADDRESS: ,.
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PROPERTY UTILITY ACCOUNT NUMBER: ; iPROPERTY OPARCELNUMBER:
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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,to receive a stormwat utility credit. Denial of this right will result in
the loss of the storm water credit. Applicant's Initial
APPLICANT SIGNATURE: DATE:
21
Submit application and attachments to: City of Carmel
Engineering Department
Attn: Department of Storm water Management
One Civic Square
Carmel, IN 46032
stormwater@carmeLin.gov
Required attachments for the Residential Cost-share Incentive
INITIAL APPLICATION ATTACHMENTS INSTALLATION VERIFICATION ATTACHMENTS
_Sketch of Site and Location of BMP(s) Photos of Installation
_Photos of Site _Receipts
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Application Fee bd U O�'i a'IJ L —t 61—�
For Department of Storm water Management Use
APPLICANT NAME: PROPERTY ADDRESS:
DATE RECEIVED: RECEIVED BY:
6�llJ 7-P OAAAS
TARGET AREA: APPROVED
COOL CREEK WATERSHED XCOST-SHARE AMOUNT �D
REIMBURSEMENT SENT
DENIED(Reason)
All
33
STAFF SI URE: DATE: / l
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