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Home My WebLink About06030085 Signed Demo 03/02/2006 14:40 3175712265 CARMEL UTILITIES PAGE 04/05 PAGE 02 02/10/2006 08:2~ 3175712615 CARMEL. FIRE Demolition Permit Requirements City of Carmel! Clay Township Building & Code E:nforc~msnt; City of Garmsl One Civic Square; Carmel, IN 46032 Ph, (317) 571-2444 Fax (317) 571-2499 !Q BIi: SUBMi'lI&Qj!'ilTH Ae.PLICATION"; Two copies of a site location map..clearly identifying the struclture or structures to be demolished, the Tax Map parcel number for the parcel on which 1~he 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. t Certain inspections are required relating to private wells, septic systems, and fuel tanks, prior to demolition. + Should approvals be required from other Stale or local government entities, or utilllles (other than those addressed herein), it is the sole responsibility of the contractor of record to obtain such approvals. . Existino well, WIlli must be plugged according to Well Ordinance A.62. Ex/sUna seotic: 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; Fuel tanks must be pumped and removed from building andlor property. 11102 Towne Road 17.13-05-00-00-012001 Adr:Jr~u of demolition Tax Map parcel # Mike RuggietO 7444 SJ1,addll,d Station Way, Indianapolis, IN 46256 r..,. " <? ' "'if <.- 'r s' Ownar(s) Name and Address ~ Additionsl Structum(s) on site' es No (If yes, please list the number and type(s) of structure on the lines provided. If 0 he structures has a separate street address than the primary structure on Ite parcel-please also include that Information.) One additicnalstructure on sitl::. Structu~ i~ ~ gazebo. n._." ..__n_nn _n__ .h____n__ ....... .... ._. nn .." 0__ _n__ _ . ............n .... ..". '___'n ..._ _n_ ___ ___ ._.'n. _ _n_.. ....... ..... _. .........__ _ _n n__n.. .n~n__ _ _ _...."~_..'.. The City of Carmel andlor Hamilton County Health Dapt 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 slanalures of the individuals listed below. (This can be done by FAX to thejr. 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. HamlFton County Health Dept; Phone (317) 778-8500. FAX (317) 776-8506. S:Pennlls\DemolitiQn permj~ handoul 1012 03/02/2006 14:40 3175712265 a2/10/2a06 08: 29 :3175712615 CARMEL UTILITIES CARM~1.. FIRE < PAGE 05/05 PAGE a3 0g(~. ff'~~ SignatuJ"ll: Morris Hensley (or representative) "6.-?--e(p (< Date Signature: Barry McNulty (or repr....entatlwl Date CERTIFICATE OF AUTHORITY Under the penalties at perjury (Indi..na Code 3t1-44-2-1), I hereby a'/film, under oath, that all of the infcmnation I have provided in this application for demolition permit is true and accurate, to the best of my knowledge and belief, and that I have not knowingly Qr intentionally provided or omlttlld any informatkm that would tend to hide, obscure, or otherwllle mislead the Department of community Services regarding the truth of the matters addressed therein. Further, I a"art that I 11m the property owner, or the authorized and lawfully appointed agent of the owner(s), that I he'/e express authority and permission from the owner(s) (and anyone with a recorded Interest or other Intarest in the property), to tak.e this requutad action, and that I agree to indemnify and hold harmle88 the City of Cannel from any claim, lawllult, demand, or damages whatsoever arising out of, or as a result of, this request or the actions of the City of Carmel, regardIng same. /...~. ~ r~ {)"2- 11 9-0'- Applicant's Signature & Date 7-/ JJI~' Date ,...., 41--1'- (Name printed) v clt;v G <--- S" !-z. "OR Applicants Phone # "L ci "'re. C'Vtt4--B Applicant's Address C" """'1(!./ City, IN ST l.{'l!I;;~ Zip STATE OF INDIANA ) .ss County of --> Before me, the undersigmld, ~ NIltlIY Public fOl" County, StlIte of Indiana, personally and acknowledged the execution of the foregoing appeared instrument this day of ,20_, My Commission ExpRs: Netal)' Public (P"nt) S:P.t1T1its~~"" petmlt nandOU1 ~ofZ 03/10/2008 14 53 FAX 3177788508 03/1e/2866 13:81 3175712615 HAM CO HEALTH oEPT CARMEL FIRE ~ 005/005 PAGE: 65 Slgnllture: Morris Hensley (or ",presentative) Daw 4-~ ,.} (j - () ~ Dllte CERTIFICATE OF AUTHORITY Under the penalties of perjury (Indiana Code 3544-2-1), I hereby affirm, under oath, that all of the Information I have provided in this application for demolition permit Ie true and accurate, to the beat of my knowledge and belief, and that I have not knowingly or Intentionally provided or omitted sny ioforrnatlon that would tend to hide, obscure, or otherwise mislead the DePilrtment of Community Services regarding the truth of the matters add,.sed therein. Further, I aSl:srt that I am ths property owner, or the authorized ancllawfully appointed agent of the owner(s), that I have express authority and permission from the ownllr(s) (and anyone With a recol'ded Interest or other Interest In the property), to take this requested action, and that I agrve to Indemnify and hold harmless the City of Carmel from any claim, lawsuit, demand, or damages whatsoever arising out of, or as a result of, this request or the actions of the City of Carmel, regarding same. ~ ..~/ (:)"2- tJ fJ-(J~ Applicant's Signature & Date 2/P/.o{. Date ^ 4/L1'-- (Name printed) {/.J{,..t; c:...- S/ (-2-"O,p Applicants Phone # L c./ ~"'L ~ ~b.J4".-B Appllcant'1 Address c:~ ~"'Ie.( City, IN ST 4. '6 )"2.- Zip STATE OF INDIANA ) 5S County of ) Before me, th, Undel"9lgned, a Notary Public for County, stqte of Indlanll, penlonally line! acknowledged the execution of the foregoing appeared Instrument this day of .20_" Notarypubno My Cornmia;"" Exp/roo. (pnn,) S!Permija\OcmoUtIcln pI;Ionnit h~ndout ~or~