HomeMy WebLinkAbout05100064-AffidavitDATE
To be
er(s) and Newly ~4ssigned Contractor
Date:
Fype of Cons~ruction
General Assembly of the State of Indiana, and all Acts amendatory thereto.
will not be used or occupied until a Certificate of
~ Services, Carme!, Indiana.
Phone
ST Zip Phone
County, State of Indiana, personally appeared
)f the fOregoing instrument this Z ~_ day of
SEE REVERSE FOR
Name (Assuming responsibility for projecO
Ernai! Address
ST
of Indiana, personally
Rev. Oct. 2003
S:Permits/Affidavits/New Builder Af[idavit