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Home My WebLink About14060069 Certificate of Insurance I _ _ _ CT��2 Exemption .Form .. �� , Owncr/T,eriant'Name �.� }%`'2(li�'wl tr1USI.CIGNI.S.�Y1'�'{�1`YIO�� LC�!'rJl� �-QX�UU�'�'�r'1 , � .. . � . Project Address:�,''��2� �.� �l �41� �'yf" �i`Yl�(�.��7(�.Suite/tloor:�� Applicant'Information: ', Name: . Phone Fax - _ �)i : . , �___) BusinessName: ' [?hone ;-Fax � ��'_ �)-- Project Inf'ormation � Change of Occupancy yes_ no_� Existing Occ Proposed Oce _ y .:: ... . . . . New Sttacture/Addition -yes_ no�: Additioiial Sc�. Et.- Remodel/Alteration : yes� no � Existing�Sq. Ft�. 3 �� 1 Project'Descrtption;;-�@ri'�OC�Q:� 0� I.t)<At�1t1G � E''eCCX�l��t'1 �A�GI� �� f��{ �S o�it�. r'��C�. � ��tcr,tic ruu�%n';� l'.ortF�re.ric� �2�rv�. M�s-1-� wi7("k. Will this pro�ect inc►ude nnyof the followirig: j� Y'�ryYtot;�2,t �� ,�y�{� �� , Electrtcal yes� no_ (Description) � Z �iV�-� .�R)✓��Ph�__)''Q��1G�-�,Q� Pli�mhing yes `� ;iio_ (Description) 2 "}`l�i1n1 r`j1 f1� HUAC .yes�( no_ (Description) � (�(��t'� r-C,�.UU(�GL-`�'I�(1 Based om e work°described herein, this�project: _ ��is'exemaCfi•omrplan filing with the IDHS, Building"Safety/Services, Plan Review. • Pcr sec 675 [AC 12-6-4-�-�-�-:&'675 IAC 12-6-4-�- .3 -� 675 [AG 12-6-4-�- Gj -�, & 675IAC 12;6-4-�,�- � is not`exemnt from plan filing with the IDI IS,;Building Safety/Services,Blan Review. Per the following explanation; And a'local buil"ding permit will nof be issued without;a constPuctiorr dcsign i•elease from: Indiaria Degattment of Homeland Security Division of B'uilding Safety7Services, Plan Review '402:W. Was}iingtoii St:, Room E'-245 ° . Indianapolis„1N.46204-2739 � , Phor�e(317);232-1431�- � This pio�ect is'subject to.compliance with all applicable rules and regulations of the State Boai•d<of . . Health Tn�e Pi•everition and Building Safely,;Commission, lodal:standards:and procedures; and local zoninb ordmances. Signature (Applican) �I�jl, `z 1: Date lQ.�( QI l� ° / : Signature„( Pr,oject Dev:-Analyst)_ , � . <" � Date � � �' ; ^' „. ... �. Sig`nature (Btulding C,ode Analyst) � DaYe __ � � �� Cityoflndianapolis ' � � Deparlmenl of Code EnforcemenC 1200 Madison Ave Suite 100: � lndianapolis,IN.4G225' i (317)327-8700 � , w•ww:indy:gov/perni its 72(3 U2009 I � � -:�