HomeMy WebLinkAbout05120048 Affidavit
AFFIDA VIT
To be signed by Property Owner(s) and Newly Assigned Contractor
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Perrmt Issue Date: I . I 3 ( l,{'.l
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Notice is hereby given that Me. (,. 1. Lc. . D.l~ A IY\,',(A,J 0+\ 0''';'' .(,rot .is no longer the responsible party for the
Previous Contractor's Name
above-referenced project and permit number, in whose name was issued for a NJ.'i \' <? tV.)' .'
Type of Construction I
~ ;)b/J (' (', C,;; Building Permit Number: ())'/ r) 0 ol/r
DATE:
to be built at ( 0 ~51
As of 1/2.~ 106 , responsibility for the completion of this project will be assumed by
" Date
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New Contractor's Name I
inspections will be performed and that the project will comply with, and conform to the Building Codes and Zoning
W,'rJ Oc f'tl2-I<E
Address of Construction
, who hereby certifies by this Affidavit that any remaining building
Ordinances of Carmel/Clay Township - 1980, adopted under the authority of Acts of 1979, Public Law 178 Sec. 1 et seq,
General Assembly of the State of Indiana, and all Acts amendatory thereto.
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("\~_ \"'0 U;f U.. ...) fila. S Ie J ~ <5,J certifies that the construction will not be used or occupied until a Certificate of
. New Contractor ...J
Occupancy (C/O) has been issued by the Department of Community Services, Cannel, Indiana.
Property Owner(s) Signature:
P~-rlE:llA;O.t") tF'J4.I)(_
(Name)
(Print)
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(03'5'1 I Ji) 101:::F b-(E.~g:'
Street Address
CftA.'lrt'~ I
City
XLi
ST
46032-
Zip Phone
('31'7) n~. b$3{
Phone
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(Name) _ ~ --::- -::' ~
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(Print)
Date
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City
ST
Zip Phone
Phone
Streef'A~dress
STATE~OF INDiANA )
SS
County of Ind iana )
Before me, the undersigned, a Notary Public for Hami 1 ton County, State of Indiana, personally appeared
and acknowledged the execution of the foregoing instrument this 26th day of
July
,20~.
06/11/09
-'
My Commission Expires:
.-
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-_.-
Judy Johnston
(print)
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SEE REVERSE FOR NEWLY ASSIGNED CONTRACTOR INFORMATION & SIGNATURE...
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Contractor's Name (Assuming responsibility for project)
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Date I
(Name of Compa )
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(Print)
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Street Address of Company
PO"^'Tr
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cry
UDJ 517 _03/0
FAX
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ST
'-16236
Zip Phone
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. . Email Address
STATE OFINDIANA)
SS
County of Hami 1 ton)
Before me, the undersigned, a Notary Public for Hami 1 ton County" State oI'Indiana, personally
appeared and acknowledged the execution of the foregoing instrument
this 26th day of July , 20~,
~,~
06/11/09.
My Commission Expires:
Judy Johnston
(print)
,,",
Rev. Oct. 2003
S:Permits/AffidavitsINew Builder Affidavit
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