HomeMy WebLinkAbout314029 7/26/2017 4i CAp1f
e o' CITY OF CARMEL, INDIANA VENDOR: 371835 CHECK AMOUNT: $'""`4,039.50"
ONE CIVIC SQUARE CALATLANTICROA HOMES OF IN
r° CARMEL, INDIANA 46032 INDIANAPOLIS
N RIVER ROAD SUITE 100 CHECK NUMBER: 314029
/26/1
T INDIANAPOLIS IN aszao CHECK DATE: 07/26/17
1M >ON
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
OTHER EXPENSES
101 5023990 REFUND 4,039.50
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**COMPLETE& RETURN
REFUND REQUEST THIS FORM TO:
Cit of Carmel
V 1 Building&Code Services Y
Pb. (317) 571-2444 Fax (317) 571-2499 wilding &Code Services
One Civic Square;
Jr�uinTa�'. Carmel, IN 46032
16090131
PERMIT #(s):
Lot & Subdivision, or Address of Construction:
ASHMOOR LOT 12 - 3496 YANCEY PLACE
(If more than one address needs to be listed and will not fit, please 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:
DUPLICATE PERMIT ISSUED
Permit # for the same lot/build is the current and active permit
TOTAL REFUND AMOUNT REQUESTED: $4039.50
nn
07/21/2017
Applicant Signature Date
KRISTIN CARLSON CALATLANTIC HOMES OF INDIANA
Applicant Name—Printed Company Name(If applicable)
APPLICANT ADDRESS:
9025 NORTH RIVER ROAD, SUITE 100
Street Address JUL 2 4 2017
INDIANAPOLIS IN 46240
city STy, Zip -
3176593205
Phone # Fax #
FOR OFFICE USE ONLY: ( zLr) �l
p Total amount for fees that ARE available for refund: Y' TCJ�(% 15c)
p Fees that are NOT available for refund:
p Refund approved by: Date: 0_
p Date submitted for Payment: � �� �� Amount Approved: d�� 5a