HomeMy WebLinkAbout05070086-Affidavit
AFFIDA VIT
To be signed by Property Owner(s) and Newly Assigned Contractor
Building Permit Number: O~ 1 (1 (J rO~
Permit Issue Date: f{ ) ) $' )o!"'
DATE: 2.- 27. - rlfp
Notice is hereby given that C 13
CrJ ,.!"i.")<< v c..'t" I 0"\
is no longer the responsible party for the
,
fq~m .{./V1J l-).<JtI
Type of Construction
Previous Contractor's Name
above-referenced project and permit number, in whose name was issued for a
to be built at q(p'1.,~
7\1 Gl4-YI'l9~f
Address of Construction
As of L - 7.'2- - rlll
Date
-A't't7f-$."I\,J uJ,>-r~{-'IOJ
New Contractor's Name
, responsibility for the completion of this project will be assumed by
e~.
, who hereby certifies by this Affidavit that any remaining building
inspections will be performed and that the project will comply with, and conform to the Building Codes and Zoning
Ordinances of Carmel/Clay Township ~ 1980, adopted under the authority of Acts of 1979, Public Law 178 Sec. 1 et seq,
General Assembly of the State of Indiana, and all Acts amendatory thereto.
'i\r \11t:(htA-J C'''' N}.-( 1'v~""I~ UD. certifies that the construction will not be used or occupied until a Certificate of
New Contractor
Occupancy (CIO) has been issued by the Department of Community Services, Carmel, Indiana.
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Property Owner(s) Signature:, '-/t '" 1 O/".J
JOWl wrck STRuM -42f1i{J~
(Name) !r'":;-:~,~',L"_,:f.i!~;~Pij9t) r5:",-,.:,~,\ i
1 G J..~ S'i/.f clJ i/I1 0 ~ f f-O f ~,C;{/J';;t:~t.~:j VI If 60 :5 Z-
Street Address I City ST Zip Phone
"','
-
oz;-z.<..~o6
" Date
........ ~
(511 ). cg'76 7'1:1 ()
~Phone
(Name)
(Print)
Date
( )
Street Address
City
ST
Zip Phone
Phone
STATE OF INDIANA
County of )td~l(.. -(Qr!
)
SS
)
Before me, the undersigned, a Notary Public for 111',6I~ \ ~J County, State of Indiana, personally appeared
,\(1~ w, '-K. ~"~Q.M' and acknowledged the execution of the foregoing instrument this --z. 'Z.. day of
.1' ....... -., "
';~~v~~ '. .' ,20 fk-.
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~" JEFFREY A. ESHOWSKY
~ . Marion County
- MyCommission ExDIres
, March 19. 2008
~-14.o~
My Commission Expires:
SEE REVERSE FOR NEWLY ASSIGNED CONTRACTOR INFORMATION & SIGNATURE...
Contractor's Name (Assuming responsibility for project)
.he~ ~~
(N.meOf~, )
(Signature of Representative or Agent)
(POOP JtVJ ~i'7
S-r- f 2-- k
2-()-1,!ob
D-qie I
Street Address of Company
.-.-.
City
ST
<.f~ko;J
Zip Phone
( 7,/7 ) 9 b i7 - 1&4:7
Phone
( '$17 ) 12-tf- b/S-Y
FAX
Email Address
STATE OF INDIANA )
. SS
County of Yl1llt~\cJ )
fl.1.MIQj
""3 -\ft - c 'f)
(Print)
-~l#\jil~t<' ,/
./
~~ JEFFREY A. ESHOWSKY
~~. Marion
_."::: MyCommls~-'-
.<.- Marcf11~00T"'"
My Commission Expires:
Rev. Oct. 2003
S:Permits/AffidavitslNew Builder Affidavit
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