160582 06/10/2008 CITY OF CARMEL, INDIANA VENDOR: T361404 Page 1 of 1
ONE CIVIC SQUARE DAVID SMITH
CARMEL, INDIANA 46032 14170 STACEY ST CHECK AMOUNT: $59.00
CARMEL IN 46033 CHECK NUMBER: 160582
CHECK DATE: 6/10/2008
DEPARTMENT ACCOUNT PO NUMBER I NUMBER AMOUNT DESCRIPTION
101 5023990 59.00 OTHER EXPENSES
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REFUND REQUEST "CO oR RETURN
G� F
Building Code Services City of Carmel
Ph. (317) 571 -2444 Fax (317) 571 -2499 Building &r Code Services
One Civic Square;
Carmel, IN 46032
PERMIT #(s): �—V 0 4 0 lO 3
Lot Subdivision, or Address of Construction:
(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:
del2c� J e perm in er ror T� on lu
v� e c ha r �n�rl�Y 3.
TOTAL REFUND AMOUNT REQUESTED: *5q Oo
Crne G t, -F 1'Iy l 1+ ouf do
Applicant Signature Date
Applicant Name Printed Company Name (If applicable)
APPLICANT ADDRESS:
v i d Sim 4+1 l l-4 I 0 S4
Street Address
Car
City ST Zip
(;I i) 5to� GLaO
Phone Fax
FOR OFFICE USE ONLY
p Total amount for fees that ARE available for refund: A E D
p Fees that are NOT available for refund:
p Refund approved by: L m Date: M
p Date submitted for Payment: a ,3 Amount Approved:
s-
REFUND REQUESTS MUST OCCUR WITHIN
RESIDENTIAL PERMITS Within 180 days from the issuance date of
the permit.
COMMERCIAL /INSTITUTIONAL /MULTI- FAMILY Within 1 year of the
issue date of the State Commercial Design Release (CDR)
there is NO CDR they need to begin within 1 year
of the issuance date of the permit.
FEES WHICH MAY BE REFUNDED ARE
Inspection Fees. Count the number of inspections
charged on an ILP application (assessed by plan review).
Certificate of Occupancy or Substantial Completion
Fees. To be refunded.
PRIF Fee. To be refunded.
Fees (re- inspection, late fees, "other" inspection fees): Refunds can
be made if it has been determined that a "clearly defined error" has
been made when a re- inspection, late, and /or "other" fee has been
assessed.
NOTE: If an ILP has gone beyond 180 days for start of construction, no refund
can be generated because the ILP is technically invalid /expired. If, however,
the applicant has requested, and has been granted, an extension of time prior
to the 180 day dead line, a refund could still be granted, all under the terms as
outlined above.
NOTE: Applicants requesting refunds for sewer and /or water permits should
be directed to the utility provider. (Carmel Utilities or CTRWD.)
S:Permits/ Forms/ Refund Request Form
��L�A�E�F����NSTR��
~^t' �"'''°"^~p
���7SI�� CATION
For Single Family, Town Home, &l� Family: N� Structures
CONTRACTOR BUILDER NAME: P2N a: tA11!'V1ffL
OF eL�-Wle(' INDIANA
RECORD: STREET ADDRESS: CITY: STATE
BUILDER's EMAIL ADDRESS: BEST METHOD OF CONTA IJ
PROPERTy NAME: PHONE: FAX:
OWNER: No T� 667 -C& "(0 ky__
STREET ADDRESS: CITY: STATE: ZIP:
LOCATION L SUBDIVISION NAME: SECTION: ZONING:
Oaf f
PROJECT LA F
ADDRESS OF CONSTRUCTION: SQUARE
SEWER UTILITY WATER UTILITY ESTIMATED COST OF CONSTRUCTION:
PROVIDER: 0 0 r me/ PROVIDER: rnel (EXCLUDING LAND VALUE) S'3S)03.
NAME OF UTILITY EXCAVATION CONTRACTOR; PLAN COMMISSION BZA BPW DOCKET
NUMBERS; TAC DATE(S); AND/OR COUNTY WELL AND/OR SEPTIC PERMIT #'S (IF APPLICABLE):
FLOOD ZONE AREA DESIGNATION(S) MAP PARCEL
0 SINGLE FAMILY
CD NEW STRUCTURE
TYPE OF CONSTRUCTION: TYPE OF IMPROVEMENT: PLUMBING 0 /vWmnOMc 7`^ C3 mvwnwupr/Iww(S) p1wnbe,�znd�naS�to�cense#`
O -4—_6g pORC*«DDDIOm(S)
#or units bein9 r�i�� DECK AooJTzom(S)
constructed attxis(���" REMODEL Which plumbing codes will ue applied u, the construction:
time:— Basement Finish only
RESIDENTIAL (For ACCESSORY BUILDING International Residential Code w/zndianaAmendments
Additions, Remodels, Etc.) osT��*somAm���
C] Uniform Plumbing Code `m/zndianaAmendments
c] ATTACHED GARAGE
PROJECT O DEMOLITION (Check all that apply for the new
Early Release Manufactured
Permit: y Trusses: _--Y r construction area)
[nAwLSpA[E O�' pO3T& us^mPIsn
�«Split: ___Y v m Sump pump- __-y�-�-m SLAB BASEMENT (vvALm]oT:__-Y__--m)
For Single Family and Two Family dwellings, additions, remodels, and/or accessory structures, this permit is valid ordy if construction commences within 180
days of the date of issuance of the building permit, and must be completed (Certificate of Occupancy issued) within 18 months of the issuance date. Class I
structure permits are subject to the General Administrative Rules of the State of Indiana (See 675 IAC 12) regarding expiration time frames for beginning and
completing construction.
I, the undersigned, agree that any construction, reconstruction, enlargement, relocation, or alteration of a structure, or any change in the use ofland orstruccures
requested by this application will comply with, and conform to, all applicable laws of the State of Indiana, and the "Zoning Ordinance of Carmel Indiana 1993" (Z-
289) and amendments, adopted under authority of I.C. 36-7 et seq, General Assembly of the State of Indiana, and all Acts amendatory thereto. I further certify that only
kitchen, bath, and Boor drains are connected to the sanitary sewer. I further certify that the construction will not be used or occupied until a Certificate of
occu,pancyhas been issued by the Department of Community Services, Carmel, Indiana.
Signature of Owner or Autfiorizeci Agent Print Date
OFFICE USE ONLY:
INSPECTI REQUIRED: Filing Fees:
Base Inspections: Charged me-
Uppei LoxvarFooting Under Reviews Cert. of Occupancy:
Rough In Meter0ase
P.R.I.F.: Additional Fees
Revi ed/Appro'v( ept. of Community Services (Date)
CITY OF CARMEL
Item 1 of 1 PERMIT RECEIPT OPERATOR: plux
COPY 1
Sec: Twp:18 Rng:04 Sub:668 B1k:19 Lot:161
PARCEL ID 1610190207005000
DATE ISSUED........ 05/13/2008
RECEIPT 28086
REFERENCE ID 08040163
SITE ADDRESS 14170 STACEY ST
SUBDIVISION FOSTER ESTATES
CITY CARMEL
IMPACT AREA
OWNER NORMA J SMITH
ADDRESS 14170 STACEY ST
CITY /STATE /ZIP CARMEL, IN 46033
RECEIVED FROM NORMA SMITH
CONTRACTOR LIC SMITNOR
COMPANY SMITH NORMA J
ADDRESS 14170 STACEY STREET
CITY /STATE /ZIP CARMEL, IN 46033
TELEPHONE (317) 569 -0640
FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL
IRESFINAL FLAT RATE 1.00 59.00 0.00 59.00 0.00
IRESFTSLB FLAT RATE 1.00 59.00 0.00 59.00 0.00
IRESROUGH FLAT RATE 1.00 59.00 0.00 59.00 0.00
2ESADD SQUARE FEET 89.00 153.68 0.00 153.68 0.00
2ESC /O FLAT RATE 1.00 57.00 0.00 57.00 0.00
DOTAL PERMIT 387.68 0.00 387.68 0.00
METHOD OF PAYMENT AMOUNT NUMBER
'HECK 387.68 1307
DOTAL RECEIPT 387.68
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
S&M Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total O
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.
ALLOWED 20
I N M F
SU O
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/ 56a3ggO 6q.d0 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
lc423 200 9'
i
Si nat
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund