HomeMy WebLinkAbout07050226 Correspondence
REFUND REQUEST
Building &' Code Services
Ph. (317) 571- 2444 Fax (317) 571-2499
""COMPLETE &: RETURN I
THIS FORM TO: I
City of Carmel :
Building &: Code Services I
One Civic Square;
Carmel, IN 46032
PERMIT #(s): [) '( D5 n~~( (J
Lot & Subdivision, or Address of Construction:
LtlY-C.:th 't"'.
(If more than one address needs to be listed and will not fit, please a
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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:J,. 77.50
104.00
0.00
.50
Do
-
TOTAL REFUND AMOUNT REQUESTED:
TCh"'n ~ ~ bJim ~~
Applicant Signature
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Applicant Name - Printed
APPLICANT ADDRESS:
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Street Address
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574-.qloCO
Phone #
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_10 - 7 - en
Date
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Company Name (If applicable)
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ST
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Zip
Fax #
FOR OFFICE USE ONLY:
o Total amount for fees that ARE available for refund:
o Fees that are NOT available for refund:
Date:
o Refund approved by:
Amount Approved:
o Date submitted for Payment:
S:Permits/Forms/Refund Request Form