HomeMy WebLinkAbout06020011-Signed Demo
HAM CO HEALTH DEPT ~ 002/005
01/13/2006 1617 FAX 3177768506 IilQ04/001
JORDAN
01'1312008 09:30 FAX 5458165 ITIES. PAGE 31/34
OARMEL UTIL
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Demolition Permit Requirements
Glty of Carmllll Clay Township
aukflnll . Ollde IIl1oroemenc Olty tJt Cl!lrmel
One ClVtQ.$qIHl...; Olll'mel,IN 4~2 Ph (317)611-2444 Fax (317) 15?'1~4119
TO BE JJUElMIJJ:IIlt wrr.l:LAefIrICAT1QN-: Two caple. of a site location map-oGle'rly
Identifying thliJ .truat...re or strulOturea to be demollsh.d, the Tax Map pllrol!!1 Plumber fOr
the JiII,,"1 on which the demolition 18 to eDo",r, end this tonn signed by the _('proprlate
dep.rtmentll. ("..fJ,ppllc01Itian ille thfSe-parttwm .VQlIaQ/e frgm the 8ulldlng.. COde
Enfol'Ofiment O"l'ce)
NOTS:
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A 88plll'lilte permit ElppllCl8tlon mu.t be complat.d per P8r~'.
Oarta in Inspections are /'8qulred relatlng to 'prIvate wells, septic systems, and fuel
tanka, prior to demolltlol1.1 .
Should approVlllle be requr"d from oth.r Ssw or local government entltles. or
1./t111t1Ii1l3 (oth.r than those IIIdCfreued l'Ie""n), It Ie the 80Ja rellponslblli1y of the ,
eonlrsotor of rGCOrd to obtaIn lSU'*t approVlllls.
~1$JI1Ia ~11: w." m41.t IMI plugged ollac:ordlng to Well On:llnance A.52. ~o ~/( ~"t4d r
Exl.tfna s6orfc: Slptlc .yatvm mU8t 1;1. p"'mped andl flllad wIth SlII1d, or "",ovad. 11 .eptlo
.y.tem Is to bG reulliId, it must be pluSS<<f Oft until ready for re.us.. ~~
Fuel 7,tnq; Fuel tanb must bt pumped IInct rsmov.d ffom bulldlnlil Bnd/or proplil. ~
JIL~.lt'J L.~IoJ.o... c,."Me..'1 ~^' J/"'/O-'30wOJ-lJ3" 0/0. 000
~~~~I .~;~~~6) ~;OM ~'fS ~ UI.~S+~+ Tu7:::~l~;~ ~~(U~
"" Nama ancl~r... \ '
, Additional Sfructutn(8) on she; YN I (8j (If ye.. please list the number and type (a) of
structure en tha lines PmvJded( If on. of the 'lructures has a IlilPfll'Glte streEtt addreGIJ Il'lln tile
prlrn&y 8lr1Jc:ture on lhe pliroel-pra8sB :aleo I~Ud. ltlllt Infrmnatron.)
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Tha Ci(Y Of C8rTr/Q1 and/or HSn1flton County Healtlt ~pt. must pflrfrJrm tm ln8pecfk;n ptfor to
demolltioll. In 0IrJ.,. to flPPlOve fha demollf/Qn p.rmJt, tht! appl/a.nr Itll'equll'ed to .fgn thIlS ftJnn
IInd obtaIn the slane ru,.. Oflhel1lr"rir{IIJt.I{t1tetJ btlllo't. (Thi$"." be done by FAX tp Chelr
omc-, .t the numb."'/~beJt:lw. Inc/lide th/~ Ct1mplfiltsd form with ell ~Tl)D"1UI
~frl1J.tv"l. (ON THE I~R" OP THIS PAGS) when you .ubmlt ytJl1r .PI' datiOn pac:kage.
1. Marrf$ Htm/l)~ 8up~or: K1Itsr r.....fn7ent OPlilI'at/o". City of CamHI.'
Phon. (317) 671.2813. FAX (317) 571.nss. ' ,
l!al1y M~NUIty: Hem'~ Cou.nty Hnlth De",-;
Phone (317) 771J..B600. FAX ~"1) 71,",606.
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CMMEl.. UTILITIE:S
JDRDAN
~ 005/005
IiIIOQ1/001
PIli<3E €I:3/1'l4
~ CCl/coe
01/13/2008 18:18 FAX 3177788508
01/18/2008 09:30 FA~ 5458185
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HAM CO HEALTH DEPT
JOROAN
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CERTIFICATE OF AUTHORITY
Under the pen..tl.. .., perju/y (Indlllfla CocIe 3~-44-2""), I hlretlYafflnn. Und'., Clllth, that ..U of th$
Information I h;aw .,rovIclod III !hie .ppllGatlon for demolition permit IlIl true lU1d accurate, to tllll
b.ar 'Of l'l'Iy knDWJed"e atId bell.f. and that J hi'" no1 knOWingly or Intentionally provided Dr
omitted Iny Itlfomllltlon thllti would eand to hIde, oblllCU"', or cthl!IW'.. mJ'lm the Cep.rtment
of Commllnlfy 80",,10" regllrd'ni the truth ottf1e m.tten; addreu.d thllreln.
Further, , Bll8elt thaI I 11m ~. praportJI owner, or the authorized anCllaWfl.llly IlppClintBcl Be-nt of
the ownlr(_'. that I hlllYe eXpnl8. authorllyand perml,,'on from the OWner(a) Cllnd IIn)/on. with.
ru~rc(.c1ln~N8t 0' othe, IIlt'8rest In the PfOperty), to e:.ke thl. requested lIOtIon. and that I _"re.
to Indemnify and hOJd hlllrmla.1I the CIty of CUrrie, from allly claim, lawsuit, demand, or damlllJ.1I
whetsoever aria In" l~ut of. or as a ....ull of, Iltl. "'q~..t or Ute actions of the City of Carmal,
...sercllng same,
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88'ore mil, the und-l'IlgJ1sd, a Notary Publlo for
ap~.....d $h.L ,)~...
insm,m.nt th/. k.) ,:ril)l or ---1t..-.-J..,..
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County, Stet. of In4ID1.. Parvofttlly
.nd lICknow/lidfilecl thelX8ClUtloPl d~'~'ror~#lllng
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