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( <br /> everett \�- <br /> �� REFUND AUTIIORIZATION <br /> � <br /> To: City Treasurcr Datc��l� <br /> You are hereby authorized to refund the following: <br /> Payee: \1 Q iD/` D.O i <br /> Address: � 7 ��,yy/ � � _ <br /> ( /1�°'J!'�i Zip 7�� <br /> Amoun[ $ ��y, n(1 . <br /> • xea5on: �i�1 B�/n1�/1nr� � G�'�ZCG'y .L:^.��c�l� <br /> ,,�rn- .55i// -/a� .iD,� �.� � `' <br /> Customer /'� ,,-�r�i- <br /> Account No. � )1JP, i� ��_RC''�QCL <br /> This amount was received by the City of Everett on (�� / ]9 �j <br /> and recurded cu City iraasurer's Receipt No. /�p ���� <br /> ❑ City Permit No._ has been returned/cancelled. <br /> ❑ Plans have been returned to this department. <br /> • ❑ A charge has been made to _the cus ome ''s account for chis refund. <br /> /!� i�t� <br />� Da[c ut orize Signaturc <br /> Buildtng Official <br /> Tit e <br /> """"'_"""""_"'_""""""""""""""""""""'_ .""_""""' <br /> Refund by Check No. Date 19 Original Receipt <br /> Attached <br /> Account Debited: Fund Dasub Llem Util Obj <br /> or <br /> • . �� �-�J Refund Noted <br /> on Trcasurcr' s <br /> . .�" �� u—y �J OEficc CoPY <br />