HomeMy WebLinkAbout06060086 Signed Demo
06/06/2006 14 51 FAX 3177768506
B5/1b/200b 10:34 3175712b15
HAM CO HEALTH OEPT
CARMEl... FIRE
Ii1I 003/003
PAGE 03
Signature: Morris Hensley (or I'lIpreMlltlItIv.) Date
~~~~
. Signature: cNulty (or I'lIp.....ntlltlv.) Da
t,f {P/bL,
CERTIFICATE OF AUTHORITY
Under the penaltles of perjury (Indiana Coda 3544-2-1), I hereby affirm, under oath. that all of the
Information 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 or Intentionally provided or .
omitted any Information that would tend to hide, obscure, or otherwise mislead the Department
of Community Se.rvices regarding the truth of the matters addressod therein.
Further, I assert that I am the property owner, or the authorized and lawfully appoInted agent of
the owner(e), that I have express authority end pannlsslon from the owner(s) (and anyone with a
recorded Interest or other Interest in the property), to take thl. requeeted action, and that I agree
to Indemnify and hold harmine the CIty of Carmel from any claim, lawsuit, demand, or damages
whata.oavar arising out of, or as a result of, this request or the action. of the City of. Carmal,
regarding eame.
"""...~
Applicanfe Signature & Data
S /11,/ 0 " .
.J7/'/o(,
Date
1'1 ,~ll,l<' c (; vC-/i t.
(Name printed)
(?o) ~71- ,'p,,"
Applicants Phone #
C/J/l....f!(... f=l(t€, De!'r
Applicant's Address
2 C:::,V,c. -'t.....~~ C"~i!d
City,
IN'
ST
4611.)"2-
Zip
STATE OF INDIANA )
SS
. County of I
Before me, the undersigned, a Notary Public for
County, state of Indiana, personally
and acknowledged the execution ofthA foregoing
. appeared
in5trument this
day of
.20
MyCammIul"" ~,
NDtuy Public
(I>nnt)
$'''onTIItoIOemcIlllOn pom1It handout
2012
" . .------
Signature: Morris Hensley (or representative) Date
Signature: Barry McNulty (or representative) Date
CERTIFICATE OF AUTHORITY
. Under the penalties of perjury (Indiana Code 35-44-2-1), I hereby affirm, under oath, that all of the
information 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 or intentionally provided or
omitted any information that would tend to hide, obscure, or otherwise mislead the Department
of Community Services regarding the truth of the matters addressed therein.
Further, I assert that I am the property owner, or the authorized and lawfully appointed agent of
the owner(s), that I have express authority and permission from the owner(s) (and anyone with a
recorded interest or other interest in the property), to take this requested action, and that I agree
to indemnify and hold harmless the City of Carmel from any claim, lawsuit, demand, or dam'ages
whatsoever arising out of, or as a result of, this request or the actions of the City of Carmel,
regarding same.
~~~/
Applicant's Signature & Date
S/t/"/Ob
,j/t(,,/Ob
Date
fI1rM/<" c(;.vt;.€L
(Name printed)
()17) 57/- 2' ,,4>
Applicants Phone #
CAt</"If;L FI{l.1i
Applicant's Address
DEf'r
2 C:V,c. 4.hl~e. C"/'?>,e(
City,
IN
ST
4 b t?)Z-
Zip
STATE OF INDIANA )
55
County of I
Before me, the undersigned, a Notary Public for
County, State of Indiana, personally
. appeared
and acknowledged the execution ofthe foregoing
instrument this
day of
,20 .
Notary Public
My Commission Expires:
(Print)
S:Permits\Demolition permit handout
2012
05/01/2005 13:41
3175712255
-. -. ......u.~.J
CARMEL UTILITIES
CARMEL FIRE
PAGE 03/04
PAGE 03
9A I .
r'
Signature: orris He'nsley (or representative)
Date
S'- ~(P-DG:,
Signature: B:ury McNulty (or "'presentative) Date
CERTIFICATE OF AUTHORITY
. Under the penalties of perjury (Indiana Code 35-44-2-1}, I he""byafflrm, under oath, that all of the
informatlon 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 or intentionally provided or
omitted any lnformetlc.n that would tend to hIde, obscure, or otherwise mislead the Departmen't
of Community Services regarding the truth of the matters addressed therein.
Further, I assert that I :Im the property owner, or the authorIzed and lawfully appointed agent of
the owner(s), that I ha~e express authority and permission from the owner(s) (and anyone with II
recorded Interest or otller interest In the property), to tekll thIs requested action, and that I agree
to indemnity and hOld harmless the City of Carmel from any claim, lawsuit, demand, or damatles
whal$o$ver arising out of, or as II result of, this request or the actlQOliI of the City of Carmel,
regarding slime.
----
~....~
Applicant's SIgnature & Date
S//IP/o (,
.F/ / " /13 (,
Date
f.11f/!../<- Ii c.. vC-1j, (.
(Name printed)
(})17) 57/- 2'''4-
Applicants Phone #
C/9/l.""1; (. r: J/f-€. DE;?'!
Applicant's Address
z C"V,C 4.....~e. C"~e(
City,
IN
5T
46 t?.)"Z-
Zip
---
STATE OF INDIANA )
55
County of )
Before me, the undersigned!, a Notary PUblic for
County, State of Indiana, personally
and acknowledged the 9)(ecutlon of thll foragolng
, appeared
InstruMent this
da~ of
,.20_.
Notary Puhllc
My Comm""'lo" Explroo:
(Prlnt)
s=~MTIrt!\Demollt!Cw'I permit handout
2012