HomeMy WebLinkAbout06090101 Signed Demo
3175712255
:178450217
CARMEL UTILITIES
1132 OFFICE BUILDING
PAGE 02/05
PAGE 01
TO' B~~UBMrrrED 1I'lW AePLlCATlON": Two copies of a site loclltlon map-olllarly ,
IdentifyIng the struehlr& or structures to be d9mo/lshe~J tf1e Tax Map parcel number for
the parcel on whIch the demolition Is to occur, and thIs form sIgned by the appropriate
departments. rApplfotltlon Is a three-pert form avenable trom the Suilding & Cede
EnfOrcemont Off1ctJ) ,
, NOT..E:
· ,A separate, permit application must be completed per parcel.
+ Certain Inspeotions are required relating to private wells, septic systems, and fuel
tanks; prlCl1f to demolition. " " .
+ 'Should ,approvals be required from 'other StaW'or loeal govemmententifies,..or,
utilities (other than those addressEld herein), It Is the sole responsibility of the
contractor ,of record to obtain such approvals.
Existina ~/I; Well must be plugged according to Well Ordinance A-62. ' ' 0 p~ W(? tf
Exlstlna $Sotfe:' S&pt~c s~m must be pumped and f1l1l1d with !taM, or removed. If septic..,..; ,
system Is to be Il!used, It must be pluglJod Off untlll'tlady for re-use. 2. S~r I' "- Tii7
. Fuel Tanks: Fuel tanks must be pumped 'and I'Dmoved from buildIng andlor property.
/3::Lo .eo,4~ ko..[) 1I.-Of-Z4,..t!Jt:J-otJ-()O<!.ooo
Add"'$$"'demolltlon TuMlip/l,./l:llI# ,
. AAlIei!:srf">/ ~scr: /.,2200 <'11, f')f~ . )."~38tJ/!.-.LJ~.
0Wn0r(1l) NSlIlIllIlCl Add"'..
. Add/tional Struc:ture(s) on site: ~ I No . (If yes, plessEl list the number and.lype(s) of
. structure on the liMes provided. If one of the struotures has a separate street address than the
pr1rrin structure on tne rlSroe8/ease also inclUde that. information'.) .
..d1, ::e-CL~ ~-~O' . . . . .
The City of Carmel snct'or HamIlton County Health Dept musfpsrform Iln InspeCtion prfr)r to
demolition. In order toapprov9 the demolition permit, the .ppllc.nt Is requIred to sIgn thla limn '
and obtallJ the slanatrims of the lndMdua/a listed below. (This .can be done by FAX to their
off1~, at the riumbe~ J/stedbelow) Jnciude this completed form with all a~m'I)Drlate' .
slanatures (ON THE REI/f!RSE OF THIS PA GE) when you submit your application par:kage.
(])
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2.
Morris Hensley, - superv/spl': Water Treatment Operstfons, CIty of Carmel;
Phone (317) 571-~!673. FAX (317) 571-2265.
Barry Mr;NuJty: Hsmlltan County Health lJept;
Phone (317) m5-8500. FAX (317) 776.8506:
S;F'om1IlMDomoIIllOn I"lrmlllmlldoot
, li'2
9/19/2006 10:21 AM FROM: Fax Hamilton County TO: 99, 13178460217, 60902 PAGE: 002 OF 002
69/14/2666 17:64 3178456217
1132 OFFICE BUILDING
PAGE 62
ilgllature: MOlTlS ,H?nSley far rep,osen,latlvG) Date
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Oat
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U turn: Barry McNulty (0' rap lento.tIve
Jea.l0ette 1_ GAJ':1NE:R,
CERTIFICATE OF AUTHORiTY
. .
hIder the penalties of perjury (Indiana Code 35-44.2-1), I hereby affirm. undef oath, that all of the
~fonnatlonl have provided In this application for demollllon permit Is truellnd accurate, to the
lest of my knowledge and belief, and that I haw not knowIngly or Intentlonelly pr.ovlded or
,mltted any Inforrnellon that would tend to hide, obscum, or othelWlse mislead the Department'
of Community Servlcell regarding the truth of the mattei'll addressed thereIn. .
'urther, I assert that I am the property ciWner, ortha authortzed and laWfully appolntsdagBnl of
he oWn&r(8), that I have express authorltyand permission from the owner(ll) (and anyone with a
ecorded interest or other Intera~tln the property). to take this requested action, and thai I aD,,"
o indemnify and hold harrnleaa the City of Cannel froin any claim, lawsuit, demand. Of damages
vhateoever arising out of, Of as a result of, this request or the actions ofille City of Carmei, .
egardlng same. '"
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~ppllcant's Address . .
,51.7-: 7/6- 29 C; '3
: Applicants Phone #
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iTATE OF INOLANA. )
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;ounty of I .
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~9fore mG, the undersigned, e Notary Public for ~ County, State of Indiana. p8lSDnallY
Ippeared JtlA~ C!d u.~' and ackrlowledged lh811xllClrtlon oftbeforegolng
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09/20/2005 07:40 3175712255
09/14/2006 17:20 3178460217
CARMEL UTILITIES
1132 OFFICE BUILDING
PAGE 03/05
PAGE 02
( W~ /lt~~~
3ignature: Morrill Hensley ("r"'P $tr....)
Date
~- /Cf-,5G
5lgnatul'II: Barry McNulty (or r&pr&IlIlm.!iV.l!l) Di.te
I
CERTIFICATE OF AUTHORITY
indor the penaltlos of porjulY (Indiana Code 35-44--2"1), I hereby affirm, under oath. that all of the
nfonnatlon'l have provided Iln this application for demolition permit Ie true and accuratll. to tho
lOSt of my knowledge and blllef, and that I haw not knowingly or Intentionally provided or
Imltted liny Infonnatlon that would tend to hIde, obscure, or othel't1(lse mlal.ad the Department'
If Community Sorvlces regarding the truth of the matters add......d thereIn. '
, ,
'~rih~r: I-~s~rt ~t I a~ thEip~perty oW'*'; or the: a~th~r1zed 8f'!C1lawfully appointed 'agent of
he oWner(s), that I have expires! authority 'and pennlsslon from the owner1s) (and anyone with a
ecorc:led lrite..t or other Infi81'88t II' the property), to take ttil. requested 8l:ltIon,and U,etlllgrM
olndllrnnify and held harml'Ma the City of Carmel froin any claim. lawsuit. demllnd. or dlUl'lllgH
thatsQQVlr arising out of, 01'8 a ....ultof. this l'Rqu08t artha actJol'l~ of the City of Carmel,
8gardlng same. " '.' , ' " ' ' , ' '
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\~Ical'lt'. SignAture & Date
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APpllGants Phone #
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.ppllcan"s Address
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TAT!'OFINDIANA )
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ountyOf ~ I
efore me. t~e undersigned. a Motary Public for
pPl!arod ~kA) ~~d"
Istrumenttllls /;j.;ei, dayOf:-\.p~-IJ--(-'
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~ Counly, State of Indiana, pel1lonally
'and acknOWledged thllllXllClltlon ofthefol"890ln9
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