HomeMy WebLinkAbout06100041 Signed Demo
09/27/2005 07:37
3175712255
CARMEL UTILITIES
PAGE 02/03
912Sn006 3:0Sl 1\M FROM'l Pbt.trtum Fri:lfl'Ht;i~:I Pl~t.inljrn PrOFHei!l~ 70. !i71~~2i35 J:'AGE: 002 or 003
,Oefllolifion Permit Requirements ,
City of Carmel I Clay township ,
, Building & Code Enforcement; CRy of Camlel
One CMc Square; Carmel, IN' 46032 Ph. (31.7) 571-2444 Fex (3H) 571-2499
TO l!lE SUBMlITIED WITI:I APPLlCATlON*: TwO caples of a site location map-clearly ,
Ident/fylngthB stroctureor structures to' be demolished, the Tax Map ,parcel number for
, the parcel on wh1lch the demolitIon Is to occur,and this fOrm sIgned by the appropriate
departments. (*AppllcBtlon ISBthree-part form avaflabfe from the Sulfdfng & Code
Enforcement Office) ,
, N.OtE:
A Se~arate permit application must be completed pe,r parcel. '
Certain Inspectlons are required relating to private wells, septic systems, and fuel
tanks; prior to demolition. , ,
· "Should approvals be required from other State 'or loCal gwemment entijies"or
utilftieS(Other than lhOsEladdressei:J herein), it Is the sole responsibility of the
conm:lCtorofrecord to ol:!taiR such approvals.,
Exlstlna well: Well mustbe plUgged accordIng to Well Ordinance A-62. Z t...le (Is i
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Existlna 5eDtJC:' Septlc system must be pumped and filled with sand, or removed. If septlCt{e~
system Is to be reused, It must be plugged off untll readyJor re-use. '
Fuel Tanks: Fuellanks must be pumped and removed ft'Om building and/or property.
ZC/M WEST /3"1' Sr /7-01 ,21 .00-/)0 ',oo7.f)OO
A~"fdemaI/tfQn 7'AJc MSIl P:IrceJ #
' JiM,,,,..,., fA'PIf,'I,NtJ " '7S'7 W~Jrpt)I"'r DI!"'~ J.,;,.".- too 1"'4M-.lAI"'t.lS IN fl;256
Owner(sl Name and Ad,ofrtss
.
.
AddftJona( Structural's) on sIte:(fii)/ No ,(If yes, please ~stthe number and.type(s) of
" structure on the lIoEll; provIded. If one of the structures has a separate street address than the
primary StrucbJre on the paroel-please also i ncll:lde that infolTnatlori.) "
1'1, '/ I ~ n. [' gR.''''' Pv":''' J.I.,JlIf '
The City of Carmel and/or Hamilton County Health Pept. must perform an Inspection priOr to
demolition. In order tllapprove the cJamoDfion permit, the applicant Is /Wfufred to sign this ftmn '
and obtain thes/anlitures of the IndMduals listed below. (Thfs ,can be done ,by FAX to their
offices, at the riumb~ listec/'belo'w) Include thIs compfeted form with a/l SDJJfOJJrlate' , '
slanatul'9S (ON THE'REVE1iSE OF THIS PAGE) when you submit yoUr appfTcatlon package.
,1. Marris Hens/ty,Supervfsor: Water Treatment Operations, CIty of Carmel;
PhOn8(317) 571.2673. FAX(317) 571.2265. '_ '
2. Barry McNult).: Hamilton County' Health lJept.; ,
Phone (317) 7t6-8500., rAX (317) 776-'8506.
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09/27/2005 07:37
CARMEL UTILITIES
3175712255
9/2512005 '~;09 Ni F!\OI-l~ P.1.~tirlum Pro~I:H.i~~ P.l;!t~l'pllm /.'::opl;!~t1!t TO: :'11-22(;[, PAGE: 003 CF OO:!"
Sign~~~8~(OrrOPie. .
.. q-. ? '7;' eCz,
Date.. .
Signature: earry McNulty(orrep""'.nlli~vo)
Date ..... .'
CERTIFICATE OF.AUTHORirv
. .. . ,. ... - . .
, '. ' . . .
Under the penalties of p.rjury (Indiana Code 3544-2.1), I hereby affirm, under oath, that all of the
InformatIon I havo prov1d&d In this application for demolltlon permIt Is true and accurate, to. the .
beet of my knowladge andbellef,aild that I have nClt.knowlngly.orlll'tllntionallypr;ovided or
omitted anylilformatlon thatwould tend to hide, ob9Cure, or otherwIse mislead the Departmenf
of CommunllyServlces .regardlng the truth of thl! mattere addressed thlll'Clln.
Furthar: 1- ~ssert !hat I am tlleptQpsrly owner, or the authorized and la$iry appOlntedagllnt of
the oWner(s), that I have express authority 'and permIssion from the Own~r($) (itildariYOne with a
recorded Ititel'Cletor otlwr intel'Cl!!t In the property); to take this requested action, ind that I agree
to Indemnify and hold hmmlass the Cllyof Carmel froin any claim, lawsult,demand, or damages
whatsooverarising out (ff, or as a result of, thiar'equest or the actions of the CIty of Camilli; .. . .
reg",ramgsamli. .... . ...... .. ... . ...... .. .
4i:?~~--. ..9-n,p(.'
/(Ppllc8ut:'s SignatUre &. Date
'9 - z.~ -d"
Dato
1ritV~ ,f. fSMt:1I.IY'i+>J,J
(Name prInted)
9'15'7 AJfHP'lNrj)~'1 f,,;r# 6dJtl
Appllcanfs Addran
:ft?- ]f.t...J9?1.
Applicants Phonel# i;,; .
.FJl)l.. 1 qo - y-S1-\
/N~J'+>>,~I'It-IS '. IN . . f'UG'G'
, City, .ST ZIp
STATE OF INDIANA I
. d. SS
CountyofrtA;M\..1()I:i. ... " .
Befor$ me, t~e underslgned,a Notal}' PubUc for I~~\,-,-rcr{
appeitred5re~-'JT~~~w.J ...
. .2. ;If) . . -.!t". . .. . .
Instrument thIs .~.. .da;,of . ~bP<EM~JL
~jii.~
Nollryp I~ ,,":_ ,
~r,j'l;:r, jiL~4,-,T(;'fl-
(pnrn) .
County, State of Ind. lana, personally
. .
llndacknowledged thUxecuflon of the.tOregolng
. 20 .cl:..,
.....)..
. ~f~51t'"' '. .0 .,FJCtAl: SEAL, .
t:'/'.,~" .Tl101~' :\
. ), . ~=:J.! J NOla,y.PUbllo, Stelo of lod:",,,..
;:. (~~:';:~:;,;:-:.Ll.' ,RSlllcfent ot Ho.mllton co~'r.~: ..(
"...; !:t,W,,,' .,My,Ctlrnmlt;lon ExPlrOJNov.11, :2.007
S:P.""'tslOomol1llon I'lnnt h,rdout
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10/04/2006 15:27 FAX 3177768506
HAM CO HEALTH DEPT
~ 002/003
9/~~/200i 6:55 AM 1RoM: P~.ttnum ?~o~~tio~ Fl~~1num fropeetl~~ 70: ~~6-BS06 PAGEl 002 OF 00]
,D.emolltion Permi,t Requirements .
City-of Carmel J Clay Township
- .. ~Ildrn\l &. bods Enforcement clty of carmel _
O~e Civic Square;Cclrma/, IN" 46032 Ph. (31.7) 1171.:2444 Fax (317) 571-2499
T~i SE-SUUI1IED WITH -APAICATlQN*: Two copies of a site location map..c:;learly .
Identffylngths structure 'or structures to be dllmolJahed, the Tax Map.parcel number ftJr
, tbe parcel,on which the ,demolition J$ to OCCur, anlji this term slgftGd by the approprlm
d.partrnenbl. ("Appl/catlon Is. three-p.rt form evalfabl. from the BuIlding & Code .
Enfon:ement OffIce)
.N~TE:
.
. A HpScata pemilt appUcatltlM must be completed per paroef. ..
Certain inspecttons are requfred relating to private wells. septlc systems, and fuel
tanks; prior. to demontlon. . .' . .
· ,- Should approvals be required from.ottier StaUfor loCal gQ1,temment-errt!ties".or.,
I:Itilltles'(Other Ihan thoSifaddrsssed herein). It Is ~ sOle responsibility offhe
contractor ,of record to ol::!tail'lsuch apprOvals. , .
i:xIstlna we/I: W&II must be plu~ujed accordir.\d to Well Ordlnance,1\-62.
- . "' , .. I
t=xfsUna SSbUC; , Septic 8~ must be pt..Imped and flllod wfth sand, or removed;. !f 8&ptlc .
. systllmls 'to be. ",used, It must be plugged ~ llntll ready for re-use. >1
Fuel Tanks: -Fuel tanks must be pumPed -and re~owd from bUilding and/o~ prOperty. .
. 'ZO!)O W$$r 13""# ST /7-Q'I.,.2/.-00.,.DO -,oD7"POD
Addl.:tu,'4iemoRUoil TIJt Nflip PV't!OJ #
'5"7 W~srpf>;A;/r })4Jre. s;,J~ talJ 11Yi>'''~A'''IJ.S IN, 1/6Z56
.
'Addition.; structure(~) on slte<fii)/ No , (If yeS, please J1st the number ~d,lype(s) of
' structure on the Ifnee provl~ed. If one of the structures has a separa,te street addnl~, then the I
primary structure on the ~lease also incl~de that. fnfomlatJOli.) 'I
/2. '/ ' ~ 1'1.. r' B,,-,u<- Pu.,;,,,, #~."u '
The City of Cam'lef sndibr H.am/fton County Hesfftr Dept. musfp&rfoIm an fnspectJon priOr to '.
:demollfJon. fn ,order to approve the demofltfon permft, the appllr:ant Is NqulriMI to sign thIs fom1 '
.nd obtaI,! ttJ~ -'Janatures ,,'the Indlvldual. 11- I'e/ow. (ThIS ,elln be done by F..uc to Mati
offfC!flS. rd.the numbertf Ilstedbe/ow) lndude this completed fonn ~ 811aDaroD1f.tte' . I.
slanatlH8S (ON THE REVERSE OF T1!IS PAGE) when you ,submit yollT application IMckag~
.1. Moirla Hensl.y,"Supervfsor: Water TFeBtment Operations, CIty of Carmel;
Phone (3'17) 571-2873. FAX (317) 671-2265. ' _ '. '
Bf/ny McNulty: Hamilton COunty Hetith Dapti .
, Phone (317) 1.7fU5DO., FAX (311) 77&';850t1~
. S:PennIla\DemolJllon _ hondout
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10/04/2008 15:27 FAX 3177788508
HAM CO HEALTH OEPT
~ 003/003
9!25/~006 8:55 AM fROM: Plati~um Proper~le8 Pl.~num P~~~~~i.~ TQ: "6-80Q6 PAGE: 003 Of 003
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Slgliatu~: Morris Hensley (or.-.preMll/irtfvii) ,
ori'.~""'l1!1itl,,~)
Oate
lV-Y-O-6
Date", ..,
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" CERTIFlCATE OF AUTHORiTY
, ,
Under thlil penltltles of peljury (Indtana Code 35-44-2-1). I he,~by affirm, under oath. that aJlOfU,e
Information" have provldiKll:n title appllcstlon for demolltlon permit Is true and accurtlte, to the .
best of IllY knowledge and belief, and tluitl htlve notkriowlng1y,orll;ltentlonl!lllypr.oVlded or "
omitWd My InformatIOn thMWO\AltUendto hIde; obscure, or (ltherY4se ml&l$lld theo.partm8llt
of CommunltySel'Ylces reg.rdlng the truth of the matte"' addreslNd thlllr8lr:l.,' . ". c,'. ','
. ." " ,'",. :.," " '.,::'.' "., " :.. "::"::. ':;:. '~ii~: ':; :: "', . ': r";., . , '. '.', '.' ..... "':.' . .: _," j":" : : ..... :":. " '; "':", ;.... ...;:: ,j' .,' ~ ~ .
Further. I ilSS8rt tbatl am the ,property C!Wrter. orth.lWtl1Qriz~d. ~if lawfullY ii~tiljt iItlen~ of
the oiNRer(s). that I have fllq)I'EISa tluthorfty, ill1d:~rmlaS'~ froJn &ie' owM~) (anda,ny.;ne with a
recordetllnterestor other httel'8jllt In the propertY); to blke thIs requestod action, and that I agree ~ '
tolndDmnlfy and hold hannle..the Clt)'-'Of Carmel from any c11ilm.lawfo/tj,dernand, or ~agil8 ,
whats~~r'~1,!9 '!)~ ~,or.8Il Ilr8,.,U!t<:lf, thhs request or th~ Ilctlons ot'titD ,CI~ of ~GI; ,,'. ' ,I,
reg~,.a~, " ".. "
~:tIsI~~atet?';ii~P~ ,," 9-~~Q~
,~ ..r, g~~/J
(Name printed)
91n klhi)~i,4li j)e..,t~,;;; tIft), '
AppIlCllnt'.Ad~re.8
.. .s17.1""~: .197/,
AppllGalnta Phone,#. " , ' ,
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~~ty"
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IN ..
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STATE OF INDIANA )
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'county<lf~\.-TClIJ"..) ,
Before me, tt1a ~~el:Slg~, ~ .~.xarY P!!bli~ ~r J:j.....,.\~~ County, State of 111~1ana. ~onally , , ,I
apP~: ~ ~~4J" '. ",' .' _rid lICknoWTedoe~ the8Xe~t1on ~th.'rOrego1ta~
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Ins1n.rmenttbhl2?I'l,dayOf,-S-kP-.JF~~.L.20~." ' "
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