HomeMy WebLinkAbout07050228 Correspondence
REFUND REQUEST
Building &' Code Services
Ph. (317) 571-1444 Fax (317) 571-1499
I
'~~COMPLETE&REruRN:
. THIS FORM TO:
: City of Carmel
! Building &: Code Services
. One Civic Square;
, Carmel, IN 46031
PERMIT #(s):
0'705o~f78
Lot & Subdivision, or Address of Construction:
_ 1
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(If more than one address needs to be listed and will not fit, please ch a prinfed 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:
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d1J77.60 ~ 'V~ ~PO
to 4. Db f-v--h; - ~:"'pP ch li)l
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TOTAL REFUND AMOUNT REQUESTED: J3:hlo. 00
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Applicant Signature Date
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Company Name (If applicable)
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Applicant Name - Printed
APPLICANT ADDRESS:
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.
Street Address ,
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City ~
317 -"F4<O- (OceCoCf
Phone #
"- 01,
ST
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Zip
""3 i7 -1 t 7 - 6 ~II
Fax #
FOR OFFICE USE ONLY:
o Total amount for fees that ARE available for refund:
o Fees that are NOT available for refund:
o Refund approved by:
Date:
o Date submitted for Payment:
Amount Approved:
S:Permlts/FormsjRefund Request Form