HomeMy WebLinkAbout06030146 Reciepts/Permits
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'~WITH APPLICATION.*: Two copIes of a sito locatIon map-clearly
IdentifyIng the structure or structures to bo demolished, the Tax Map parcel number for
the parcel on whIch the demolitIon Is to oceur, and this form signed by the appropriate
depanments. ("ApJ)IJcation Is a three-part fann available from the BuildIng & Code
Enforcement Offl~e) .
NOlE:
· A separate permit application must be completed per parcel.
· Certain Inspections are required relating to private wells. septic systems, and fuel
tanks. pl'tor to demolition.
· ShCluld clpprcvals be required from other State or local g.avemment entIties, or " .
utilities (,,u,er than those addressed herein), It is the sole'responsiblllty of the .. - .
contracll>r of.record to obtain sUoh approvals. , II ., /E>>f,'I "".de
.. . w~ 6..-
ExlstlnC/ WtJII: Well must be plugged accor:cllng to Well Ordlnll.npe A-62,€Jf Jb<L-~
.Exlstfna 5eDfic: SllptJe'system must be pum~ and filled with sand, or removed. If septic' ,
s)'5tem is'to be reused, It must be plugged off until ready'for re-use, e~.PT/>A:>
. , u~9'''':~
Fuel TankS: Fuel tanks must be pumped and removed from buildIng ancl/or ltroperty. ~/'j"W;;.
, .. . J2.-f<r1f1 !L~F:<:jt-5" bC_ ';)c>nc:/JII'''<
3'1$0 AI /3.(;8 sr, , J-P/1,pILc;e{e.<?up:;w~)
At1dress of dGllloJltIon 7U Map PaffHJl #
C' ~ Il I' () ""Y"?~ I 1-1-/:;: !>~ J
Owner(8J NlllI1e and AddnlP
Additional Strur.:ture(s) on site: .!!E:/. No (If yes, please list the number and type(s) of
structure on the lines Ilrovlded. If one of the struotures has a separate street address than the ' .
prl1:nary structure on the parcal~please also include that Information.)
/- hrrro<t'
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The Citl of Carmei ana/or Hamilton qouniy Health Dept. must perform an inspec;t/on pri~r to .
demolition. In arc/arto approve the demolition permft, the applicant Is requIred ~;Sig1J'''J~ form
and obtain the slanatures of the Individuals listed below. (This can be d~IjQ.Jw.J:.JrJJltjr-t!.lelr ,
offices, at the numbors lIsted below) Include thIs' CCimpleted form w1th..aif~pproDtiiite::;%, . ,
slttnatures (ON THE REVERSE OF THIS "AGE) when you submIt youY.jaPPllcatlo/J. pac1(~ .
, . . :: : ..- -';::. ; ~'
1. Moms Henslej/, SupervIsor: Water Treatment OperatIons, CIty St-tia.rmei;' - ./ .,. f
Phqne (317) 51'1.2673. FAX (317) ?,71-2265. '. '....__.......-< ,/'
2. . Barry MpNpIt'j: Hamilton County Health Dept.; '-_.;,' I.: .',. <::.'.....
Phone (31'1) 7i's.8500. FAX (317) 776.8508, "', ..,.
S:PermllolOomcriQcn Plll!nlt handout
10/2
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03/21/2005 08:52 3175712255
_. MA~-~,~~O_OJ! 11.Q~ Qags An ann.
CARMEL UTILITIES
FAX NO,
PAGE 02/03
p, 03
~~~
Signature: Motrls Hensley (orrepresen
" "
.?> .- ,;2/- eCo
Date
Slgnatul'$: Barry McNulty (or reprGSentatlve) Date
CERTIFICATE OF AUTHORITY
Under the penalties of perjury (IndIana Code 3544.2.1), I hereby,affinn, under oath, that all afth~
information I have provided In thIs appllcatlon for demoli~on permit is true and accurate, 'to the
best ~ my knowledge and belief, and ,that I have not kncwil:lgly or intentlorially,provldeCl or '
omItted 'any Infonnatl(ln that would tend to hide, obscure, or otherwls~ mislead, the 'Dep~rtment
of community Servlcs,s regardiflgthe truth of,the matters addressed therein.' ' '
. ~ ~ .. . ." ,_ ". , .' _...,. ." .w, " " .
.- "~ Further; I'~s~~rtth~t ls;'ih'e propei:tY own~r; or theaut,horlzed ~nd I~WfuiIY appoi~ttld age.1tOf'
, the owner(s), that I haVe express a,uthority and permission from the i:lwner(s) (and anyone with a
recorded Interest or other interest in the property), to take this requested action,' and that I agree'
,to in!:lemnlfy and hold harmless the' City of Oarmel from any claim, lawsuit, ~emand, or damages
whatsOever arising O~lt of, or as 'a result of, this request or the actions of the city of Carm...
regarding same. ' .
~1~' '4~~jo~:..
,Applieant's ature & Date, . .'
l)v....;. ;.?~-~~.
(Name printed) '. '. '
Date
. "~-t7;a'7?-'J,.'7I,'2..
Applicants Phone,#
u,,~'.. (~"'lIlI."'" C'!)~1J'''
Appllcallt's Address
, ,
. labe> ~,oo'\ol::.. -:Z\O':>'S'IJ\\\'t' ~N I.lb0"77'
City,ST
- ZJp
StATE OF INDIANA )
55
. County of ~r..o,tlt' ...-J
Before llie, the ,llndBrsl~lned, a Notary Public .for j),tJ ?);aJl;" county.' state of Indiana; perSonally .
" ,~~':ClI;l.'''~.tI.xr-,. I, Pl:4 ,aridaCknOWledgedtheexecutlon'Ofthe.foregQ[ng
Imrtr4IT1ent~15 '.idi-l,. day Qf WI JH? p J.J .2M &.' ,
,~~.
., ~QI.r;'Publ'
j{'" .2jlu~ ' ,
trill-' ...
M CommJOOlCll ExpIl'1l.:
,~~(JJ)i.p. '; tl..!.;J..e.e.-f<,
l~~"~ ..
~:P.rm1ls\Oem.ni", perm~ """,loll!
, 2012.
; -...
03/20/2008 13:41 FAX 3177788508
__ ____ ~~~20-20~~_~OR..09:_~~ AM me
HAM CO HEALTH DEPT
FAX NO,
IiiI 003/003
P. .03.
"
,
,
..'
nsley (or....p...ieritlltlve)' pate
..
, ..3 J '2./,) 1-;1.//7)(0 . '
Da ' '.
CERTIFICATE OF AUTHORITY
Under the penalties of perjiuy {Indiana code 35044-2.1), I hersby,afflrm, under oath~ that all of th.
. Infonnatlon I have provlded In' this applicatldri for demoli~.lon permit Is true and ~eeiJrate, to tM
best of my knowledge and belief. and .that I have not knowlOgly or Intentlonallyprovldeii or '
omitted 'allY lnforma1lon that would ten.d to hide, obseure, .or othelWl.,. mIslead the bep~rtment .
of CommunIty $ervlo'es regarCl1flg't!1e .truth of .the matters addressed therel~.." . . '.
.. - 'I ' ..'_ .' '..' ,.. '_'I . . ' . .' ." ,..' .
Further; f~58rtt~~i ".m'ih~ "r;;Pa~ ~n~r; or theauth;;~l%ei:i and l'iiWfliiiy appointed agent'ot'
the owner(s), th~t I haVljI expreS8 a.uthorlty and pe,~isslon from the Owner(s) {and anyot;le Wl~ a
recorded Interest or ott:Jer inte~st in the property), to take thIs requested action; and that I agree'
. to Indemnify and hold harmless the City of Carmel from any c;lalm, lawsu~, .demand, or damages .
, whals08!wr.'ar!slng out of, or as a result of, thl. ...quest or theaC?tlons of the City of Cann~l,
re'gal'~lIrig silrne. ........ . . : '. ..... .
4ts?~ :~{,~lo~:.',
. Apphc:ant'lI atura & Date, '
"b'~..,'" l_9~1IA'
.. (Name printed) .... .
Date
. .
. .
. . '~i'7';I3'7t-."71::2...
Applicants P one.#
l2... ~~~ 7~ ~~..... t;D~+r.'
Applicant's Addrells
. ,
1'01)00. i..,,). O04-l=-.,,",,'&>'::>S\.l\\\'f"J:....! 4.(,,0,'7'
City, .ST
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.. STATe 9F INDIANA '. ) .
S$
county of , (;np.clE .' )
Before lrie, thUlnd8r8lgn.d,IINotBry Public for /0" '1~ . C~unty,'~ of !nc:llani;, Pt!I'~iGl~allY .
. <!ppem;8t1-\"~~ L. P#--r-rj '. arid acknowladg.d th~ ~~e~on""fthe foregQlng
.' 1~~~~iitthl5' ~~Io. i1ayof 'W\A.fPj/.20dlJ," '.
, '. ...... :/(:1'//2-:.
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