HomeMy WebLinkAbout06060225 Signed Demo
08/28/2008 12,45 FAX 3177788508
El5/19/2ElEl6 14: 12 31 75~0580
HAM CO HEALTH DEPT
UPS STORE CARMEL IN
@002/003
PAGE 01
",;:,,;J, Demolition Permlt Requirements
'I,,^ City of Carmel I Clay Township , '
Il;> \. It It Bulldlnll & Code Enforcement: City of CIlnnel
~ I~GI ~, ,one CMc Square; Carmel, IN 413032 Ph. (31'7) 571:2444 Fax(317) 571-2499 ' ,
"VJ' j9 BE SUBMITTED W!n:L8f.fbICAnON*: Two copies of it. site locetlonmllp-ctearly "
' identifying the structure or structures to bGdemoll.hecf, the TaX Map parcol number for
the parcel on which the demolition Is to occur, and this form slgn.d by th..pproprlafe
departments. (*Appltcation is a thre&-part ,fonn evsllable from the Bui/dlng 'Code "
Enfo~.nt Office)
~:
A separate permit applica~on must be completed per parcel. , '
Certain Inspections are required relatJng to private wells, septic systems. and fuel
tanks. prior to demolition. ' ' , , '
· "Should approvals be required from other Staw or I~I government entities, or i
utilities (other than those addressed herein), It Is the sole responsIbility of the'
contractor of record to 'obtain such approvals.
&/.stIna well: ' Well must be plugged according to Well OrdinanC$ A-62. . , ,
' , , I
er&Una HDtlr:: 'Septrc system must be pumped and filled with sand, or nlmoV8d, ' Iheptlc
. . sYstem Is to be reused; It must be plugged off Until ready for 1'&-0..
Fuel Tanks: Fuel tanks must be pumPed and remoVVd from b~ildlhg and/or propertr.
1:Y8 2foJO ~r SW C~{ :j;J ~3~ 11.I--~q'25'..I(rO(r()Ofj.CJ.9b
Add,.... Of'r/WJloJltfon Ta.\(' _ p"rca/ t# ' .
.
.
o.nel'(.) Ne,". IInd Addl'lisll
I
Addftlonat Stfuature(s) on site: Yes I @ <If yes; please list the number and typ~(s) Of
structure on the lines provided. Ifone.ofthe structures has a separate street address then the ,,'
prlmary stnJc:ture on the pereel---please also Include that infoJTnslion.) .
'.
2. ,
Mon1s Hensiey, Supervisor: WatDrTnMtnMntOperatlons, City 'of CfInnei: '
, Phone (317) 571~2673. FAX (3,11) 571-22615. ' ' . . .
Berry Aff:Nulty: H.mllton COunty H..1th Deptr
Phone. (31 T) 776-B6oo. FAX (317) 776-B6IJB. '
,W&L 't-~.~
rl~ 1~2,..,
, a'lIermIl8\DornoIItIon P\IInlR llImcut
08/28/2008 1248 FAX
e5/19/2BB5 14:12
3177788508
317574B5pB........ ___
HAM CO HEALTH DEPT Ii!J 003/003
I
UPS STORE CAIiMEL IN PAGE B2
, (U~ ...,,,....'- I..... ~/ f-:;' l'f-(/~QO
SIgnature: Morrl9 Hensley (or Illpre.."tatlve)
Date
, BtJJ71j Me Nul /:j
(ol~o/p
Date
CERTIFICATe OF AUTHORITY
Under the penalties' of perjury (Indiana Code J5044-Z.1), I hereby amnn, under'oath, that all of the
Infonnation I have'provlaed Iflllils application fQr demolition permit is true and aecume. to IJie
best of my knowledge and belief, and that 1 haw, not knowingly or Intentionally provided or I
omitted any infonnatlon that would tend to hide, obscure, or otherwise mislead the Departmerrt
' I
of Community Se,rvices regarding the truth of the mattel'$ addressed therein.
, I
Funher, I assert that lam the property owner, or tl)e authorized and lawfully appointed agent ~f
the owner(s), that I have express authority and pannlsalon from thf!l owner(l) (and anyone with II
reCorded llite...st or othe,r interest In the property). to take this requasted action, ilnd that I agree
to Indemnify and hold hannless the City of Canner from any claim, lawsuit, demand, or damages
whatsoe Ing out of, or u a result of; this ...quest or the actions Qf the City of Cannel,
rega
P fs Signature & Date
O'''~JHIl a CcN:;'711YCrr~
9T7i.v, C 5PJl.LIC/C
(Name printed)
5e" "We
!;la/t10
f I Diile
3/7-sSl - :LfAl./w
Applicants Phone #
t.jgl/ L C~m(l ( tiP #312-
Appllc:ant's AddlVse
Cv12mfl
City,
P
ST
1../ '0:31-
Zip
STATE OF INDIANA
CountY t>>f !ltJ;, J 'iIzHt
)
$$
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Before me, theunderelgned, ~ NOllu)' Public for
appelU'8d s-leve^ ~IJI.II;,-
, 1
I f,( clay of
/~/' Ihn
COU"ty, $tate of IndIana, Pllirllonllly ,
. and ClcknOWI8dged the IiXlICUtlon or the foregoing
ry ubi.
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