Name and address listed on the first few lines will determine how the refund check is issued and where it will be mailed.
Refund may be subject to a processing fee - 10% of refund total (not to exceed $25.00).
Single refunds of $1,000-$19,999.99 require approval of the CFO (or designee) and Department Head (or designee). Refunds of $20,000 or more require City Council approval.
R
Community Development Department, Permit Center
City Hall 425 N. El Dorado Street Stockton, CA 95202-1977
REQUEST FOR REFUND
State Zip Code
Receipt #
Permit #
Name:
Address:
City
Telephone numbe
r:
Amount of refund requested:
Date paid to City
:
Total amount paid:
Situs address:
Reason for requesting refund:
Contact Name:
I Certify under penalty of perjury that the information provided is true and correct.
Subscribed and sworn on this __________ day of __________________________ , 20 _____ _______________________________________________________________________ Customer Business Name
_______________________________________________________________________ Signature
FOR OFFICE USE ONLY
Approved by: _______________________________ Date: ________________ Department Head or Designee (If over $1,000.00)
Approved by: _______________________________ Date: ________________ Chief Financial Officer or Designee (If over $1,000.00) Account No: _______________ ___________ ____________ ___________ Trust Accounts – please forward to Accounting for Approval Ext
425 N El Dorado Street
(Revised 09/14/23)
Note:
See footnote
Net processing fee:
See footnote
$48,895.21
utility line footage was reduced during
installation from 25,581LF to 12,319LF
ATTACHMENT C
____________________________
____ $25.00