HomeMy WebLinkAbout07010132 Signed Demo
FAX NO,
~ 004/011
~ 003/011
PAGE G4/11
~OO./O\C
p, 03
01/18/2007 1721 FAX 3177788508
01/18/2007 15:08 FAX 5458185
Gl/16/2GG7 14:!G 3i75712265
O,/g~/ZOg7 1':~2 FAK e409190
JAN-09-2007 TUE" 1Ci: ae At!
HAM CO HEALTH DEPT
JORDAN
CA~MEL UTILITIES
JOROAN
~T~~~ Demolition Permit Requirements
City, 01 Carmel ( C18)' TClwn.hlp
'-' !lUhaln\l & 0.,08 E"j'otcemonl, Oily of Ollrmel
OM ~lvlQ $~U8r.1 C.PTI\8r, IN ~~0!2 /lh. (:!I1~) '11-20444 "ex (31T) 571.2499
IQ ~Ii..SUIlMITTe. ~: Two COpl"'. ofa alte leoatlon map-oleatly
Tdorrilfyini the stl'l~cture or IlItrLlct ,...1 tc tlll demon,hed, th. Tax M.p parcel number for
th9 parea' on whlc:h the demol/tlo Is to occur. and thle fonn signed by tho app~Gprlatli
depart:rr!antll, (.ApIJJf~II'tJon ~ II ulNI!l-P'''' fol'm lIvtJ/lab//t "'0", !he /II,lI/dlng & Cede
Enfcl~a,".nr Qffl..r.) ~
NOTe:
. A ..paiT1l1e permit liIppll tlen muat be C10mP/eted pllIr parcel.
.. Certain Inspection. are riOClUll'8d relatlnll to ~r/Vat$ wella, lIl!!1~tlc systemll, .tndftJel
telnkU. prIor to ~8moll~hbn.
. Shr;>uld approvals be re~lred' from other State or locel government entitles. or
utilltle& (olhQr than thQ:tie addressed hWlllln), It Is th. $ole respOl'lslblllly of tn.
oontNllc:tor of record lD I;) taln such appr~ls, .
Exist/no ~/I: Well mUGt be PIuJ90d llceordln; tel Well Ordin&nall A-62. ~iH-r"'r ;:fe~T~
lhdstlna B8Df/cI Steptlc .ystem mUtt be PUlt1pecf lInd flll_d with sand, or I'9moved. If Il:liIptlc
a)(llt.m I. to II.... '~, It mUllt b, plu9ged off untJJ rlfady fDr l'II.use. <{q~
,flUI8I T&nb; IIUIlI ianl<<l mu.t b pumped and I'8moved from 1:IlJUdlne and/qr pro~~. I
.- '-t 70 I tv ~+ ..<< 1'"-...( T'foU1: /.,1r.-..1A<i
A,"1drr>SJI." <fomf>llt!on 1'4ll'M*p F'areelll
~ 7'i- ~. ~zt/fJ
Addition,,! StrU()tul'td(s) on alt.: Yea N (If yea, Pless.. list the number anCf ~(5) of.
IIIlrucwre on the lines provIded, If Qn$ 0 the mctures hili 1II Separl!ll& street addrf>$8 than the
primary ClrI./oturli on the parceJ-please Isg Include thet Inforl'l'1atton.)
~./
I
__ :1- _'
ThQ City Q/ C.nnel e~l/cr Hl.lmf/(Qf/ OQIIA(y Health Dept must etfcrm '"-:- --
:~';oIlt1o~, In ~trJsr tel ~'Ppro~~ tns dQmQ lion p.rmJe me .pp;t~nt 1$ :'~/:,~-:O;,::o;J: fOrm ..
~~:::';~:'/?~:~'H:.~~R::~W ~ ~';.~~~/~..CCItlPf.1:d ::::r::::. :~':,~~Z';:J: thwllr
~ w"en yo II lIubmlt YO"'r.ppll~.t'rm PS(;kdpe,
MOnte HGl!llIey, Supervl8or: W. r Treatmenr r;Jp~t10'" OJty of Cann I
Phon. ($17) ~7'l'-je~. FAX (317 611-11268. . .,
Bany McNulty: Hamilton OOlln H.,Jth O.pt..
PhonQ (31'1') ""fj;.8$OO. FAX (31'1 7"6-9606. .
81,oo....IIoI_tg", Mm.1I ~.'UUI
1.
2.
.",~
FAX NO,
~005/011
1aJ004/011
F'AtlE 8li/11
IiiIOCStC18
p, 04
01/18/2007 17.22 FAX 3177788508
01/18/2007 15:06 FAX 5458165
al/1~/2ea7 14:Sa .176712255
0110B/20~7 11:~2 r^~ ~4~S'ee
JAN-D9-20D7 rUE 10:sa AN
HAM CO HEALTH DEPT
JORDAN
CAR~~ UTI~ITIES
JO~DAN
~~..:.,. d ~I/~ ~T
9h:lnlllll,..: Moma I'1_nsl.)I (or n1pr...nlall~..
'-.,
~)~htL~"ttr 1),6{0/
SIgnature: B I;NUlty'(ar,"p"'.." tlve) "tte
Data
1- /~_ 0--,
OJ5RTIFICATE OF AUTHORITY
Under th. pIIn.ltr.. of perjury (lnellana Code 354402.1), I herutly afllnn, under oath, th...t all of the
Informatll:ln I have provided In this application for demelltlon p8tl'l'llt ,. true Ind 1==UAlt., to the
Illlfl gf my knowredlJ!llInd ballef, and that' have not knowl!'l~ly or 'ntontlonally provldeli or
Dmlttod Ilny lnfotm.tlon that would t.nd to hId., ot!8oU"', elr oth.rwl." mlllle.ad the Department
of Qommlolnl1y elarvlQIIs .....slllTdlng tho truth of the mattal'l!l 2lddl'BllB8i:l th.,..ln. '
Furth.r, I....rt thlll 1m the property owner, or the 8uthorlz'ad and lawfullV Ilppolnpad sgent of
the awn.,-(.}, that I hOlY. e;ll;p~ authorlt)' and permissIon from thft awn8r(t1) (.,..t .nyone WIth II
nlIll:Qrded 'niDrest or other Internr In th. property), to taQ Ihl. ~qU'ned Betlon, IInd thllt 11IUr'81t
10 IndeMnify .nd hClld harm I iii.. th. Olty t1f Cantl.J from Iny ollllm, b1WtUIt,. demand, 01' ctamlilllG$
wh.teoeVllr .I'IlI'n, !:Juf of, ar.. 8l'81;JUlt Qt, thl. I'l:IqUQort; or the acUon.. ofth. City of Cannal.
Alll!ltdlnEl '.me.
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Appll~n . AddAl..
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Apj)1 cantS Phone
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Zip
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STATE OF INDIANA }
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Count:l",m~tJ~ -->
EI_fore mlt, ths undIlI'*IQl'lecl, .. Not.'Y PUl)IIo!'or
ilIppelft'k~h ~
lnWLI"'.nt thl. 7' t"-:r of - J &/t.-? ~7
County, lStll!e of Imlhln_, penrclnlllly
and .oknOW'IICfCled ill. ellClIltlltlllln ofth. 101'4l!l01n9
.20a2.
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