Refund Request Form
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10 309 E Market Street - Smithfield , NC 27577 Inspections @ johnstonncgov Mon - Fri 8 00 am - 5 00 pm 919 989 - 5060 Johnston County Refund Form Permit number _______________________________________________________ Applicant Name ______________________________________________________ Property Owner Name ________________________________________________ Property Address ____________________________________________________ Has work commenced Yes______ No______ Is the permit expired Yes______ No______ Reason for refund detailed explanation required ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ If Refund approved Make check Payable to _________________________________Phone________________ Mailing Address ____________________________________________________________ Requestor Name print ___________________________ Phone __________________________ Requestor Signature _____________________________ Date____________________________ Company ________________________________________________________________________ Staff intake signature __________________________________________ State of _______________County of __________________ seal The above - named individual personally appeared before me on this day who , being dually sworn , deposes and says the statement is true and correct This , the_______day of________________ , 20__________ Notary Public Signature ____________________________ My Commission expires _____________________________PageOffice use only Calculation of refund completed by staff Initial Permit Fee ________________ – 30 of Permit fee 100 dollar minimum _________________ – Homeowner Recovery Fund fee _________________ – Zoning Fee _________________ – Plan Review Fee _________________ – Other deductions _________________ Total Refund _________________ Director approval signature _____________________________________ Once refund is issued , permit is voidedPage