HomeMy WebLinkAbout07010131 Signed Demo
FFlR NO.
~ 008/011
~007/011
PAGE alOin
~01 lie 1$
P. 03
01118/2007 17 22 FAX 3177788508
01/18/2007 15:06 FAX 5456165
Bl/16/2BB7 14:SB 3115712265
01/06/2007 11:03 FAX 545B165
JAN.08~2007 iU~ lO:3B AM
HAM CO HEAL1H DEPT
JORDAN
C~M~L UTILITI~S
JDRDAN
~ .,,~ . DemoUtlon Permit Requirements
City of Carmtal J Clay Township
l!IulldfnQ " OQde E~le_"'arrt: olt')l "I C""".I
'-' -.Q[iimlY' C)rw ClIIII.. SqUI'I; =11T1l.1. IN 4$tJ32 Ph. (1017) $71.3444 ~.~ (317) 5T1.24l/i
o I! SUElMITTliD WITH AP~LICATION.: Two oopleai of. illite rooatlon mllp-oleurfy
~Q~'fylng the 'tJ'LlotU'" or atructuras to bla demolished, tl'1' Tax Map parClllI number fOr
the parcel on which the demal~lon I. to occur, ancl tl1l, fonn algnliltJ byth8IlPPl'<lptl.t8
dltpllrrmenbl. tApplio.tIon (II . th,.e.part form l!JY:liJ~ble from the Building & Code
=nfg~ment Oi'l'li~Q)
NOTE:
~
A "I'lerate permIt applicatIon must be completed per parcel.
C",rtlli" in.pe=tJons ere requll1lcj relallng to pn'vllte weill, !Ie!)tJc: eyetIBme, and {lJel
ranks, prIor tQ c1.moll&lon.
SHoUld .p~rQ"ata blI requlr.d from other state or local gcWtmment ent/tlh, or
utllltlall (othar than tho". eddrMOllIq hilr&i,,). It /. thlil 80le raspcnslbl/ily of tha
Qontr2l;:tor of reCQrd to obtaIn 8uc;h apP/'Qval$. .
e)(/~t1nt1 Witl/' Well mUSE be plugged acoerdlng to Well O~rnll/'l"e "'.02. # Ii!. <:4~~(. ~rh
Jaxl"rina -a"fJ! lJe"t/c Cystem "111.' b. pump..d 1Ill~ tlrJed wtth sand. or removed. It sop~ _
syvten'1ls to be reu..eI, It mu.t b, plUtll1.d off until ready for re'U811. _ , __
Fuel tank, mUlt _. pum~.d Inl;/ removed from bulldlnli/llnd/or pl'Qper1y.
oIs;f~9?'-#. S)>~ .
." ~ . ~. /1 ~ ~ M'PPe/cfla. ---r- .
,I/. 71'< A r 7~ , o:-L.~ ~ 2f/~
Clwrler(1I) N,ri1, end )lddI'U'
Al1dftlon611itru~rll(.s) 0" .1(... Ye-s /~ (If yes, plesse lilt the number end type(s) of
etnJoture em th. /lna'l;trgvided, If ono oftn;';tructurell has a illepllhlttl etrget address IMan th~
. Primary lltroature OI'T lIle pell"CleJ--plel!ls9 alsCllnolude tMst Information.)
.
.
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Fue{ r:f1Ib,
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The Clry Qf eft"';1 smilef HamQfon County H../ffl J:Jllpt. must pl!ldorm .17 /n.~ct/on p~ to
dSfTlOlft/on, In order to "pp~v. th. ""moIltlQn permit, the ~PPflc.nr 1$ reqtJll'ed to .tgn /hI. form
en (Thfa oah bll rtfm~ by~.JIXto rh.lr
offl~. .t thD flumblll/'5I 11$ h. ow) IncJIICfe this camp 9tvcf form wlrh 4UfSDI"CQrI!Ilte
slanatures (eN TH. Fo!lfVE/fSE OP THIS "AGJ!') when JlOU submit ~lIr ~Pp/Joiltlon paokilgo.
1. Mom. 11_"${.Y, $UPuvillol'1 W.tw 'r,..tnlllnt Op."'tIQna, CIty o'C.rm.I'
'-' Phon. (Sf7) B71'.2fJ73. FAX (317) 671.2266. ,
Z. Bsrty McNUlty: H.mlfttJl7 CoulTfy H,.lth D.pt;
Phon", (31'?) "7~"S6CO. /IIA.)( ~,,, 71s..lIf()(J.
"J~~JUrl'l~."-'dGl,,1t
-
-
1Ilta
FAX NO,
1l1I008/011
1iI00S/0ll
PAGI;: 09/11
Ili012101S
P. 04
01/18/2007 17:22 FAX 3177788508
01/16/2007 15:07 FAX 5458165
61/16/2ee7 14:50 3175712265
Ol/OS/200' 11:53 F~K ~4~g1g5
JAN-09-2007 TUe 10:38 An
HAM CO HEALTH DEPT
JORDAN
CARMEL UTILITI[S
JORDAN
.-
9vr,,~ A-/~-- ,,~
91l1nature: MorrJ~ H.nlSley (or I'iIpr....n I Date
~~,h1e-~
(-/,?-_e,
1111./6 7
,
CERTIFICATE OF AUTHa~1iY
Under the ~n.ltl.. of p.rJury ('"dlsn. Code 3544..:1-1), , ftill'lOPlI' .mrm. under 01''', th., all Qf lhe
Information I have p.rov/e1ed In thlt applIQltlgn for demolltlon penn It I. true and accurate, to the
billet qf my knowl'dSll and ben." and that [have net k"owtngry 01' l.ht8nUGlnaIl1 prQvldlld or
~mltt,d IIny Information that would tend to hldo, Clbaeu",. or o1herwl.& ml.li_d the Depllrtmant
or Qomm'lnl(y Sarvl,s8lI reaardlng the truth of the mllttal'll addN...d tt1...ln.
FI,/rth.r,, n..rt thlll.m the PfDpertlt' owner, or the lIuthorl:ll.d Arld lawfully appolntod egont or
thll ownfll'\s), thet I have expnaa. authority and plInnlolon from tn. awner(s) (lInd l!Iny<;lno with II
recorded 'n","t etr other Inta~.t In the prepllrt;y), to take this requested .ctlon, and that' agnlll
tQ Indemnify Incl hClld hllrmlulII the City cf Cannel fMm any claIm, laWBIoIle. d.-mand, or dlmllges
whatligaVDr arlelng ClU' 01, or aa II NSIult of, thIs I'IIIquest cr ttI. 8000ne of the City of Carmel,
regardIng ume.
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"'AplffilSant'a Si ature & Data
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STAT! OIPINPIANA )
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Ihfo... lIllO, th. I,/n.,.111"8Cl, 11 Notary PubllQ fQr 411f1b ,n Coun"" .....- _ r ....
"..,... J L7 --r- J L! .~. ...-... WI n"'!llllll, personally
:o.PIl6lr.d=:Lt:.!!!.h &..~~- -r/~s . ... ok I
. -- IIn..;l naw IIdge.d tIT" 8l(~Il,=,n ..1 the fDragclns
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