HomeMy WebLinkAbout07010127 Signed Demo
FI\X NO,
141002/011
I
~001/011
I
PAGE 02/11
I
IiiIOO,2/01S
: p, 03
01/16/2007 17:21 FAX 3177768506
01/1S/2007 15'05 FAX 5458185
6/2007 14'50 ~1?S?122~5
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J~~-08~,007 ruE \0:38 AK
HAM CO HEALTH OEPT
JORDAN
CARMEL UTIL!TII1:S
JORD^K
OQmorltlon Permit Requirements
CIty 0' Carmel.' Clay Town.hlp
SuJldlne & eelSa Iinr"rcomenl; city gf c.rmeJ ,
I~.V '11\0 elvlo Squ8re, C.rmll, IN 4603.\2 Ph, (317) 5714444 F.x (~17) 5'11....tPP !
TO ,. 'UelMJm!J;? \."16TH APP..L~ATlOPi.: Two gopl.. 0' . .r~ IOCl.tlol1l'mlP_I.~tIY
IdentifyIng tJ1i"8i/'u<:tu... or .tru Ute. to ba de,"olh5h~d, the Tax M.p plroef num~er for
the Plroa' on whllt;h fh. clemc/ltlol1la to ocour, I!Ind this form ./gned by the ./,pl'cllJ'late
clepartmenbJ. ~~lppJlt!JiI!ItJQn I.,. th~P4rl form .vallabl~ from the .ul/dlng & Cotle
enforcement Offh=.)
~OT~:
· A &lilplJrate permit QPpllQillion ml.llilt bli l:lQmp/eted per part::el. '
· Certsl" Inspections are requJred releting to private wells, septIc .Ylltema, and fu.,
tank., prlgr tQ demolition. I
. S"ould !I1'~rOvlIls be required from othar StaN! or loeal QClVemment ltntltles, or
L1~lIti.. (other then tho",. addressed ~erl1in>, it i.the sorllJ re.pon$lblllly of the
contra<:tor 0' reGQrd to obtain such approvals. ' I
Exlat/rla WIlli! Well rnullIt be j:llu99.d aCQOrdlng ro Well Orc(ln..no. A~. ;/ Df ~ <<::
6xt.t1na ..0rTal tt.ptlo .Y'NM ml.l~ be pumplld ahq filled wltI'l aand, or removed. If .eptlo
')'*torn r. to be l'9ua.d, It must be plug;IiJ" gff I.Intfl nt.d'~ for te-us., I,.l"~
F.llfll Tanlt!l;. ,l'uol tanks mu~e pUMped and ""roved from blJlldfng :JndJor propRrly.
.v, 97 ..sk~,er i
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Ow".r(
Adl!ilHonllJ $trul;wre(ltI) rim .ftel Ye, ~ (If Y'., preE!se list the numb.r and l)ipe(s) Of
ctruottJre on the /lnltll provIded. If on. oi~r;Nrell has II separate IWeet address Ihllln the
primary lltruotUI'f) on the plIl"CeJ-pl_sa alllQ Inolude thot Information,)
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Th" OijY of a.rmel "neVe.- Hamilton County HWlfth Dlitpt. mil" perfom".n Jl'ltJP.otJan prtar to
QlitmoJitlon. In ~fdtJ.- ~ flPPfO..-. thfl dflmo/ltJrm permit, tJl. ~ppIIG8fJt is raqulffltl tQ :sign !hI. term
and obt&/n ths slan.trJ;1t' "'Pit IntlIV,/u.1a JIl1t'd ~/olf. (ThIll ~n be darr" by ~ to their'
offltJfiUI, .t tJr. numb..,.. 1$t&d eJow) '/It1/Ude this compfwr.d fo",., 'l(/.fh 4.11 .o~""orla,-,
lI'an..tv/'b (ON THli R_'V1EREiE Of; THIS PA (Ill) When you IIUbl'nlt your flppl/r;atlon Pflckeg~.
1. Morr/!I HM!!l/9Y, .lJP~r; Water rfe4tmMr OPet'al/ons City af Cannel'
Pho1t~(311) fl71-2!1J. "(4)((317) S71-US~ ' ,
.crry M.tNuliYl H.mJltolJ County Health Dept./
Phon. (31'1) h".Qsoc, FAX ~1") 71&1506.
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S:PllnTllbl~&:In 'PetmIc lliIn~~
~ wi ~ !L~/,p /07
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~N-~~~~
F'AX NO.
1i1I003/011
~ 002/011
PAGE: 113/11
!iloo~/o'8
P. 04
01/16/2007 17 21 FAX 3177768506
0~/16/2007 15:06 FAX 5458185
1l1/1&/~ae? H:p!l. .". 31:~~:~~~~&5
JIlN-ONOQ7 TUE !,J;3S AM
HAM CO HEALTH DEPT
JORDAN'
CARMEL UTILITIES
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CERTIFICATE; OF AUTHORITY
Und.r the p.n1lftI.. of p.rJUry (Inc:\llInl 00.;1. 15S.....oa.1). I hereb)f IIMrm, I.Indar _th, that all of the
Inforrutlon I hay. provlclld In thl.!ll!lppllc.atlal'l for demolition permIt r. true anclaecUl'li., to th.
bern o;f my know/lld!iJo and beUef, end that I have not Icnowinlily or IntentIonally prO\lldlld or
omItted 'ny informltlon thllt would tend to h/d_, obsQunt, Dr othlilrwf". mlll,"d the DepZlrtmant
of Oommunlty S.nrlcll. regard'n" the tNth of the matte... liIddl'8lllaed theN/no
Further, I aS88rt thllt I 11m the property OWl'llr, ar thtl authorlz.d and lawfully appointed IlIGB", t of
the ownel'(&), that ,/lay. ')C~""e lluthorttyand parmlllle/On from the own.re.) (IInd -nyon_ wit" III
raC"orcled Internlll! or gthor In19",lIt In the prcpany), kJ take thIs I1Ilf,,",etecl.Otlon, aha that 'IIGree
to IndQmnlty and hold harm'''. the city of C.IlIn1QI1rOlTlany or.lm. ItW_",t, demand, or c1amilil$S
wl1etao.vwr arlalng CIU' 01, or.. iI ...lIl.Ilt of. till. I'1ilquest or the act'on.~ of fh. City of Carm.,.
""gardln ..me,
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