213757 10/17/2012 CITY OF CARMEL, INDIANA VENDOR: T0002534 Page 1 of 1
p 0 ONE CIVIC SQUARE JOHN J SCHNEIDER CHECK AMOUNT: $3,369.93
CARMEL, INDIANA 46032 12505 WEST ROAD
s� ZIONSVILLE IN 46077 CHECK NUMBER: 213757
CHECK DATE: 10/1712012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 3 , 369 . 93 REFUND
**COMPLETE &r RETURN
.,:;. REFUND REQUEST THIS FORM TO: j
BUrldrna&Code Services City of Carmel
t"o - b Building &r Code Services
Ph. (317) 571-2444 Fax (317) 571-2499 a
One Civic Square;
-- Carmel, IN 46032
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PERMIT #(s):
Lot & Subdivision, or Address of Construction:
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(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#.)
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Please print or type the reason for the requested refund, and specific fee or fees
which are requested, in the lines below: i
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TOTAL Rte,' ` `D . OUNT REQUESTED:
Applicant Signature Date
Applicant Name-Printed Company Name (If applicable)
APPLICANT ADDRESS:
lr� .
S et Address
City- - -- _ ST Zip
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P ne # Fax # t
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FOR OFFICE USE ONLY:
p Total amount for fees that ARE available for refund/
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p ees that are NOT available for refund: ,� !
p Refund approved by: J��C( PJT l�f A ll Y�r� Date: I D 1-2,
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p Date submitted for Payment: Amount Approved:
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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)
"If 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/ine, 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 State 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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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.
T ALLOWED 20
IN SUM OF
j2d-
fNJ 4&C,
9 -3
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
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
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Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund