HomeMy WebLinkAbout06030005 Signed Demo
02/20/2005 14:37 3175712255
CARMEL UTILITIES
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JAN-28-2006 THU 01 : 33 PM
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FAX NO.
p, 03/04
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91S" : Morris !U!nl
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8lgnature: .arry Mcilllult)' (or ....,,....ntatlV.) Date
CERTIFICATE OF AUTHORITY
.
Under tho ponlltlfllB cJf pecjul')' (IncllMB ~ 38-44-2.1), I hereby amrm, under oath, thatlllll of the
lnfonnatlon I haw PlO\lldecf In &hIe application 101' domolftlon permit'll true Qnd accuratlll, to the
bNt of my knCl'NledGIl and 1:leIIef, and that I have not knowlngly or Intentionally provlded or
omitted any Info/'lmlflon thet would and to tilde, obscure, or otherililBe f'/lf8lead the Department
of Community hMcllNl regllrelln; the truth of the mattai'll addre8lled therein.
Further, 'IlIH1t thlt 111m the Pl"DPlrty owner, or the authorlml anellawl'ul~ appointed agant of
the owner(s). that I haw eXpl'DiJB 1Uth!H1tY llInd permlIJ8lon from the ownar(s) (and anyone with ·
~ Inte....t or lither Internt In the propIrty), to take this naquustad ICllon, and that IIG"'.
, to Indtmn/fy and hOld hlft'lllllGll the City t1f Cannllll from sny claim, 18W8lof1t, demand, or clamagee
WhatlCNMtl' en.Ing crut of, or as 1\ mull of, this requeot or the actlons of the City of C41nnel,
reprdlng urn.. ,
"-,,,Cl. .Q~ "r:' ~~
~I~~atur.a Date
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(Hme PrlntecI)
.p / 15/01.0
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Appllcanta Phone' .
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ApP/lclnf8 Add....
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CIty,
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STAT!! 01' INDIANA )
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Ief.. me, 1M u~ICln8d, . Notary Public for
appencl
Inttru'"'/It thla __ day gf
County, State oflndlanll, personally
and acknowl8dpd the ex.cutfon of the fortlto1nt
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02/09/2008 18:08 FAX 3177788508
HAM CO HEALTH OEPT
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FAX NO.
P. 0.4
IltMture: MOi"rl8Heneley (or ,..,,....ntatIv.)
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SIfIn8W"': IIIII'IY MoM (or tepl41-' ."'!he) Dmte
CERTiFICATe OF AUTHORITY
Uncler ow penal_ of perjury ~ndllUltl Code 18 II~ 2-1), I hereby IIIffIrm, under omh, that all of the
, InformatIOn I hIM' praVlded In this eppIlcldGn for dtMnOlltton permit Ie true IIftd accu...... to the
best of my 1U\GIllI!edse and belief. end fMt I haw not knoWlnsIY or IntllfttloneUy provided or
amltt8ClQ InfOImllillOn that VlfDI,\Id tend 1G hIde. ob8OUra, or otherwI8e mlldead the Dep8rtment
of community 8eM08lll "a6rd1n; the trUth of tho mattal'a .cIdrMeeCI therein.
Furth8r,' MIl8ft ihcIt 18m the prDfMtJty owner. or the auttiotlPd and lawfUlly appointed agent of
thG awner(1I). ttlat I have ...... authortty and permlAlon from the owner{s) (end anyone with $
rtOONIlIId In.... or aIMt ...earMt In tM property), to take this requested action, end that 1 agl'M
to IndemnlfJ end hold tuvrn.... the CKy ell Carmel fram any dalm. '..ult, demand. or dlUMB"
whBiaever lII1"n& out of. <<.. 0 f88UIt of, thl, requM or &he ~ of the City of Carnie!.
1'flI8I'd1tt'11lJJIHI.
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. AppIIalftt'l'I Slgnetu... {Data
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(Name prtntecl)
Appt~nw Phon."
Applioant'G Addr8$G
City,
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,STATE oF INDIANA )
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County'" ,
Before milt U\tl unclenlllfltd, II HotlII')' Pulllle to,
,
append
InatnlrMnt thl8 .., of
county, eteoflndlflna. peraonally
lllnd aaknowledged th. exeoutlon of the fOl'lllSlolnQ
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