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everett <br />Le <br />To: City Treasurer <br />REFUND AUTHORIZATION <br />Date /2- Z.9- 87 <br />You are hereby authorized to refund the following: <br />Payee: <br />Address: 19/2 <br />G �c c'E7T G�J9. Zip 10,9O1 <br />Amount: $ /977 Zz <br />Reason: �(J 4,p,gt/Tl�-E �,e S�OFWi9C,C <br />,DNS.-79C1 !%TiD� <br />Customer <br />Account No, <br />This amount was received by the City of Everett on 19-El <br />and recorded on City Treasurer's Receipt No. O-F/o <br />Citykaj lIBZ 6 urn 4a O{ ' <br />Permit No.(�r .3f�9 has been -- �+� � l <br />,rx <br />❑ Plans have been returned to this department. <br />❑ A charge has been made to the customer's account for this refund. <br />Date j Authorized Signature <br />Title <br />Refund by Check No. Date 19_ Original Receipt <br />Account Debited; Fund Basub Elem Util Obj Attached <br />L. I , or <br />Refund Noted on <br />W LW u� <br />' Treasurer's <br />Office Copy <br />