205339 01/12/2012 CITY OF CARMEL, INDIANA VENDOR: 365935 Page 1 of 1
ONE CIVIC SQUARE STEVE FRY
CARMEL, INDIANA 46032 6353 FERGUSON ST CHECK AMOUNT: $113.10
INDIANAPOLIS IN 46220 CHECK NUMBER: 205339
CHECK DATE: 1/12/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 113.10 BLDG REFUND
1� a +cap, COMPLETE RETURN
REFUND REQUES 1 T THIS FORivl TO:
�R Cit of Carmel
Building Code Services y
Ph. (3L7) 571 -2444 Fax (317) 571-2499 Building Code Services
4 One Civic Square;
Carmel, IN 46032
PERMIT #(s) I o 0 0 7 3
Lot Subdivision, or Address of Construction:
(If more than one address needs to be lis d 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: t
o 0ny V
c-
j1pp
1�,Jj OCT 17 201
TOTAL REFUND AINIOUNT REQUESTED: 1 1
Appli ant Signatu a Date
e 2 �1�,j G ec-v,c Inc
Applicant Name Printed Company Name (If applicable)
APPLICANT ADDRESS:
Street Address
-City Zi
P
Phone Fax
FOR OFFICE USE ONLY
p Total amount for fees that ARE available for refund:
p Fees that are NOT available for refund:
p Refund approved by: Date:
p Date submitted for Payment: Amount Approved:
REFUND REQUESTS !MUST OCCUR WITHIN
RESIDENTIAL PERMITS Within 180 days from the issuance date of
the permit.
COMMERCIAL /INSTITUTIONAL /MULTI- FAMILY Within I 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
v Inspection Fees. Count the number of inspections
charged on an ILP application (assessed by plan review).
6 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 160 day deadline, 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
Prescribed by Stale Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev, 1995)
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
�e— V Purchase Order No.
Terms 1 Le 2 U Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
D Cr D
Total
I 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
IN SUM OF
3� Y11Y r� u Sr,N�
S T
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO #or INVOICE NO. ACCT /TITLE AMOUNT I hereby certify that the attached invoice or
DEPT. y ce y invoice s),
D DR 39` 0 1 c7 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
20
t i ature
tle
Cost distribution ledger classification if
claim paid motor vehicle highway fund