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Home My WebLink About06010125-Signed Demo , /<\~;;f C~~ /'V' . ''7~ ,/ -o:>,.\\TNF.HsF,:( ! '>.v, '1(0 , '< i Demolition Permit Requirements \ . j City of Carmel I Clay Township "'" IND N~// Building & Code Enforcement; City of Carmel ~__I~/ One Civic Square; Carmel, IN 46032 Ph, (317) 571-2444 Fax (317) 571-2499 TO BE SUBMITTED WITH APPLlCATION*: Two copies of a site location map--clearly identifying the structure or structures to be demolished, the Tax Map parcel number for the parcel on which the demolition is to occur, and this form signed by the appropriate departments. (*Application is a three-part form available from the Building & Code Enforcement Office) NOTE: A separate permit application must be completed per parcel. Certain inspections are required relating to private wells, septic systems, and fuel tanks, prior to demolition. Should approvals be required from other State or local government entities, or utilities (other than those addressed herein), it is the sole responsibility of the contractor of record to obtain such approvals. ..........,. -iiiSting :Well: .- -M, r "..;. /Existing septic: .; -,., , ...- ..- -. .....,.- . - . . . Well must be plugged according to Well Ordinance A-52. Septic system must be pumped and filled with sand, or removed. If septic system is to be reused, it must be plugged off until ready for re-use. Fuel tanks must e pumped and removed from building andlor property. , i1 Ta I ~pp~~ I;} iJj 0 39 (JJD , r033 (l ' ~~- ner(s) Na e and Address Additional Structure(s) on site: Yes ~ (If yes, please list the number and type(s) of structure on the lines provided. If one of~ctures has a separate street address than the primary structure on the parcel-please also include that information,) The City of Carmel and/or Hamilton County Health Dept. must perform an inspection prior to demolition. In order to approve the demolition permit, the applicant is required to sign this form and obtain the sianatures of the individuals listed below. (This can be done by FAX to their offices, at the numbers listed below) Include this completed form with all appropriate sianatures (ON THE REVERSE OF THIS PAGE) when you submit your application package. 1. Morris Hensley, Supervisor: Water Treatment Operations, City of Carmel; Phone (317) 571-2673. FAX (317) 571-2265. 2. Barry McNulty: Hamilton County Health Dept.; Phone (317) 776-8500. FAX (317) 776-8506. S:Pennits\DemolitJon permit handout 1012 01/23/2006 14:35 3175712265 CARMEL UTILITIES F'~'tG~ c:.1:..:Li ~.; ~ C1W0 griaturv: Morris Hensley {or I'IIpI'888IItIltlve II< I - :2 "3 - EJ (-:> Date Slgnat~re: Barry Mc:Nulty (or I'IIpI'II...nlBllv8) Date CERTIFICATE OF AUTHORITY Under the penalties gf peljury (Indiana Code 35-44-2-1),1 hereby affirm, uncler oath, that all of the .' Information I have pl~ded In this application for demolition permit Is tnJe and accurate, to the . best of my knowledlle and belief, and that I have not knOWingly or Intentionally provided or . omitted any Information that would tend to hide, obscure, or othelWlee mislead the Department of CommunIty Servll;es Nlgardlng the truth of the matte,. addressed therein. Further, IlI8t8rt that I am the property owner, or the authorized and lawfully appointed agent of the owner(s), that I hive express authortty and permlMlon from the owner(a) (and anyone wIth a mcorded Interest or ,)ther Interest In the property), to take thla requested action, and that I agree to Indemnify and holl~ hannleu the City of Carmel from any claim, lawault, demand, or damages whate08Ver arlalng out of, or IlII a result of, this request or the actions of the City of Carmel, regarding same. ". 1-..2~ --0 b Date ::., .ll \1 eM !( / . Applicant's 519 t :W Date r Ii ~ ... ~;.;;'JI</~ frfo~~ .. lfJ":;.!f.f,[;,.:;J/5 ~(J; " ~ '/ ~)u.) 2c.'t) ~ ,jJ ;6 . (} / / (J .- APPlfClnt'. Address r:K.~ ~I-\ CTYI 'i h d$ (j 8T Zip .,~_._---.,---~-- ----~...__....~_.._---~-,~-,~.....__.~-,.......~_._,----- STATE OF INDIANA County of J ss -1 . Before me, tho undorslgn'ld, a Notary Pllbllc for lIppeared County, state of Indiana, pensonally and acJcnow/edged the IXllCUtlCln of the foregoIng .20_.. Instrument thli dllyof . ~ PuIll,. My c.....,laI.. Ex""'" lPl1nIJ 9:i>o~Itv\D8lnaifflon poITTIJl htl.doul '012 . 1:d Wd9E: 10 98<11: EE 'U"r 8BP60BS~,r,: 'DN X~~ SLN3Wl~~ ~~~WHJN3H: wo~; 01/23/2006 1620 FAX 3177768506 HAM CO HEALTH OEPT 14 I) ...1 :~: ,/ 1:1'):; , F"RDI'1; BEi'l:HMARK APARTMENTS FAX NO. :13175Be94SB Jan. 23 2006 01:31P~ P4 -:i....., ...... ........ ,"'_, ~ l' ~ -- """"q """"'1'1 I ture; Ba~ Me (or I'1IP"HnflItlvej " ~ Ollte ~ ~.2,~ I Dfo CERTIFICATE OF AUTHORITY Under the pen.,tl. of perjury (Indl.na Code 35-44-2-1), I hereby 8ffIftII, under oath, that all Of the infonn.t1on I have provided In thl8 application for demolltlem permit I. true and aeaurate, to the best of my knowledge and belief, .nd that I haw not knowIngly or Intentionally provided or omitted any Infoftll.tlon that would tend to hide, oblleu.... or otherw1a8 ml.lead the o..-rtrnent of Community S.Nlces regarding the truth of the matters IIdd.....1KI therein. Further, I assert that I am the property owner, or the authorl2ed and lawfully appointed agent ~f the owner(B), that I hllV8 expIVU authority and parml.,on from the owner(a) (and anyone with 8 recorded InteNst or ather Intereat In the property), to take th18 l'Iquested action, and that lag.... to Indemnify and hold h.rm.... the City of Cannel from any olalm, lawsuit, demand, or "'mages whahoever ariSing out of, or .. . l'Mult of, thIB rBqU88t or the actlol18 of the City of Carmel, regardlng,8ame. 1-..;2.?; .- 0 {; Date Appllcanfs Slg Date ~' ~; LKI=S~ ftf; k4 . M~l/r!I- Orll5 dJJ (N. ,if_ C'fo ~T Ql-'~ -'9:,.....; t- S '"?3QS-W2Q) ,~f~ ST Ytdlf0 Appl cant'. Address City, p STATE'OF INDIANA ) sa CQunty of ) Before me, the undel'lllgned, a Notary PublIc for .ppe.recI Instrument this County, state of Indiana, personally and ackn~ the llX8CIItfon of the foregoing day of . .20_, N~PubIl" MyObtIHliL lon!xpIrM: (Prlrtt) S:_llIIDomoIIlIcn pe<mIt IIIndcM 2at'2 .