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DATE: Epn I I '3/2.0u1
Building Permit Number: () 5 0 q 004,-/
Permit Issue Date:
10//0/1)5
. ,
Notice is hereby given that Do UIfJ; ra n (, II is no longer the responsible party for the
evlOus Contractor's Name ....
above-referenced project and permit number, in whose name was issued for a R friO vrxAfh^-
Type of Construction
to be built at fil h.rH' L',IAJ.[. rcdrr<Lf. 't/V 1-/(003;;2.
Address oj Construction!
As of ~ J (. I 2DV I , responsibility for the completion of this project will be assumed by
Date
k-PY\ ;llru,MKl
New Contractor's Name
inspections will be performed and that the project will comply with, and conform to the Building Codes and Zoning
, who hereby certifies by this Affidavit that any remaining building
Ordinances of Carmel/Clay Township - 1980, adopted under the authority of Acts of 1979, Public Law 178 Sec. 1 et seg,
General Assembly of the State of Indiana, and all Acts amendatory thereto.
kFv1 MrLarCIA-
certifies that the construction will not be used or occupied until a Certificate of
.,New Contractor
Occupancy (C/O) has been issued by the Department of Community Services, Carmel, Indiana.
Property Owne-r(s) Signature:
(Name)
0(-;jJR L lJeJ~
J
Gf11/t j 1*1 M 1-
(Print) j
IN
: .4)r3/oT
Date' ,
. -- .-
~311 -p!)~ \;If'W C-I:.
Street Address
, 1(\~~<1f\~fDk1
-.fl~one
51'
l.-)ID:J~S
Zip Phone
(3\-1) :e3'3 -8;)L/7
(Name)
(Print)
Date
( )
Street Address
City
51'
Zip Phone
Phone
STATE OF INDIANA
County of l'1 1+((, ION
)
ss
)
Before me, the undersigned, a Notary Public for M PrR./O 1'1 County, State of Indiana, personally appeared
bOo" Ie. .1. -!-I e;./ Ci (+ and acknowledged the execution of the foregoing instrument this ./ J f~ day of
..1 Afr:/~ -~. ,20 () 7 _
~ ~,xj 95~ Fe-b. 02--/, :2 O/ii~
'~~/.._. N ry~iiblic J05"-f C. Fe+ler..J My Commission Expires:
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(print)
SEE REVERSE FOR NEWLY ASSIGNED CONTRACTOR INFORMATION & SIGNATURE...
/
Contractor's Name (Assuming responsibility for project)
STATE OF INDIANA )
I I._I L_~S
Countyof~
Before me, the undersi~ed, a Notary Public for _~~rVU ( -h5'lA County, State of Indiana, personallY
appeared k.e 1'1.. IVI { (I {J..f tu- and acknowledged the execution of the foregoing instmilient
thisJU~ dayofBrril ,200l.
~.~~~W ff~(~~L~n~x/,,~Ol{
--," ,':ZL ~
(Print)
Rev. Oct. 2003
S:Pennits/AffidavitslNew Builder Affidavit
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