HomeMy WebLinkAbout05060135-Affidavit
AFFIDAVIT
To be signed by Property Owner(s} and Newly Assigned Contractor
DATE:
~/?~0
Building Permit Number: D-567 6 0 ;' -5 S
Permit Issue Date: &./ ~ ;c/c S-
Notice is hereby given that '::3' 4/k~ 5 {AI&" " ~
is no longer the responsible party for the
Previous Contractor's Na~e
above-referenced project and permit number, in whose name was issued for a R<'-::-s /PF;V:t-//fL KL~rh6 )>E~
Type of Construction
to be built at 3-'0""/;9 //i/ /3/>"~..s:c;;r-
Address of Construction
As of
-'Z/ 9/6 Ii?
, responsibility for the completion of this project will be assumed by
, who hereby certifies by this Affidavit that any remaining building
Date ....
C //cAlf'. d/!J.-r-p
New Contractor's Name
inspections will be~performed and that the project will comply with, and conform to the Building Codes and Zoning
'Ordinances ofCim;eIlClay Township - 1980, adopted under the authority of Acts of 1979, Public Law 178 Sec. I Jt seq,
General Assembly of the State of Indiana, and all Acts amendatory thereto.
C #E./.f.:1;. c:J,::;;;-:r/;7'
certifies that the construction will not be used or occupied until a Certificate of
New Contractor
Occupancy (C/O) has been issued by the Department of Community Services, Carmel, Indiana.
Property Owner(s) Signatnre:
~~~. (l fJ.A
(Name) (/
C#L"A T -r D /Q.7d
(Print)
...Z/9/1f Go
Date
.3~.y7' W / 3/..F~:sr-
Street Address
C ,q/Z-EL
City
-L/i/ 5"'~ 0 .s L-
ST Zip Phone
(S;'/') 733-.Y75;7
Phone
(Name)
(Print)
Date
Street Address
City
ST
Zip Phone
( )
Phone
'- '.
STATE OF INDIANA )
= I . ..J'S
County ofc..p;an.,_d./~ .' r ....
Before me, the undersigned, a Notary Public for cpftt~ County, State of Indiana, personally appeared
~ 29. ~.;t~ and acknowledged the exec~tlOn of the foregoing mstrument this 9 -tI, day of
4~ ,20~.
~?N(LJd~dcb-/r: )
(PdLr~dl -fj-. l;1/nid;J IDYl
SEE REVERSE FOR NEWLY ASSIGNED CONTRACTOR INFORMATION & SIGNATURE...
Contractor's Name (Assuming responsibility for project)
C/-/?A 'f () /2 711
(Name of Company)
(;{'~ 0 ~~
(Signature of R),JJresentative or Agent)
..:z/ 1'/0 G
Date
cI!5/z;r ~ (') '27/7
(Print)
3~9j? 11l/ / ]/S?- jr;/"
Street Address of Company
(' 11 /=<h( E '-
City
JI-. A/ "?Lk 0 3" ~
ST Zip Phone
(.5 /;> ) ?.J'J "d??7
Phone
( )
FAX
,
G- , D~Tj.Jj"3 ""6/ .C "'~
Email Address
STATE OF INDIANA )
74 / . SS
County of '7Tt:2-~
Before me, the undersigned, a Notary Public for W~ County, State of Indiana, personally
appeared and acknowledged the execution of the foregoing instrument
9+1,. ,20~.
!l
4. lJedd;':jton
;2D )3
(Print)
Rev. Oct. 2003 "-.
S:Pennits/AffidavitsfNew Builder Affidavit
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