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Home My WebLink About07060116 Signed Demo Demolition Permit Requirements City of Carmel! Clay Township Building & Code Services; City of Carmel One Civic Square; Carmel, IN 46032 Ph, (317) 571-2444 Fax (317) 571-2499 TO BE SUBMITTED WITH APPLlCATION*: Two copies of a site location map--clearly identifying the structure or structures to be demolished, (on paper no larger than 11 inches by 17 inches) the Tax Map parcel number for the parcel on which the demolition is to occur, and this form signed by the appropriate departments. (*Application is a three- part form available from the Building & Code Services office.) NOTE: A separate permit application must be completed per parcel. Certain inspections are required relating to private wells, septic systems, and fuel tanks, prior to demolition. Should approvals be required from other State or local government entities, or utilities (other than those addressed herein), it is the sole responsibility of the Vt contractor of record to obtain such approvals. NJxistinq well: Well must be plugged according to Well Ordinance A-62. l-ltltExistinq septic: Septic system must be pumped and filled with sand, or removed. Ifseptic A system is to be reused, it must be plugged off until ready for re-use. tJl 'Fuel Tanks: Fu~1 tanks must be pumped and removed from building andlor property. tlr5l~ -c~~ u. Address of demolition TowN _ ~t f:evJ()~d UC Owner(s) Name and Address , \ . . . 1/- dl-~:rCO-ro-Ol~a:o Tax Map Parcel # Additional Structure(s) on site: ~ / No (If yes, please list the number and type(s) of structure on the lines provided, If one of the structures has a separate street address than the primary structure on the parcel-please also include t at inr~rmationJ)' '-LI"L' 5, "I, f.""Y\ .1 e! (\.. '\1, ~ \ \ roW>. I f) ____.__...._._._."________.____n___.__m____.____...____"".........._____"....__...."."_"__.___....__~_______,...._"_____.,.."---.-.----,.------...~-- The City of Carmel and/or Hamilton County Health Dept. must perform an inspection prior to demolition. In order to approve the demolition permit, the applicant is required to sign this form and obtain the siqnatures of the individuals listed below. (This can be done by FAX toltheir offices, at the numbers listed below) Include this completed form with all appropriate . siqnatures (ON THE REVERSE OF THIS PAGE) when you submit your application package. 1. John Mascari: Carmel Utilities. ;"~ ~ +- l2b~ Phone (317) 733-2855. FAX (317) 733-2053. 2. Barry McNulty: Hamilton County Health Dept.; Phone (317) 776-8500. FAX (317) 776.8506. S:PermitslFonnsJDemolition permit handout 1012 Mar 19 01 09:26p Richal.d Huffman 3 lc3cA1~ /fi511 - 115--'1 p2 ;f;~7-o ? Date Signature: Barry McNulty (or representative) Date CERTIFICATE OF AUTHORITY Under the penalties of perjury (Indiana Code 35-44-2-1), I hereby affirm, under oath, that all of Ui'_ information I have provided in this application for demolition permit is true and accurate, to thE. best of my knowledge and belief, and that I have not knowingly or intentionally provided or omitted any infmmation that would tend to hide, obscure, or otherwise mislead the Department of Community Services regarding the truth of the matters addressed therein. Further, I assert that I am the property owner, or the authorized and lawfully appointed agent or the owner(s), that I have express authority and permission from the owner(s) (and anyone with" recorded interest or other interest in the property), to take this requested action, and that I agree to indemnify and hold harmless the City of Carmel from any claim, iawsuit, demand, or damage~ whatsoever arising out of, or as a result of, this request or the actions of the City of Carmel, regarding same. Applicant's Signature & Date R,~~~ (Name printed) !6<L 1f~1a/' "3/'1- r:::, (O~3003 Applicants Phone # 1/9' /3 / OW1<fL d Applicanfs Address G-r~ City, It( ST lfW82 Zip STATE OF INDIANA ) 55 County of \ Before me, the undersigned. a Notary Public for County, State of Indiana, personally appeared and acknowledged the execution of the foregoing instrument this day of .20 Notary Public My Commission expires, (prinll S:Permlls/FonnslDemOiltfon pelToit handout ,. 20f2 06/13/2007 13:30 FAX 3177768506 Mar 19 01 09;28p Richard Huffman HAM CO HEALTH OEPT 3 ~ 003/00:3 p.2 SIgnature: John Mascarl (or l1IP/'8S8ntst1w) Date ~. '-~ r~ t'14~~1..~1 101 Signature: cNully or I'IlfI tIve) -=-- I Date . CERnFICATE OF AUTHORITY Under the penalties of peljury (indiana Coda 35 dW.-1), I hereby affirm, under oath, ttIat all of the Illf...nnatron I have PfWided In this IIppllcation for demonUan permit Is we and accurate, to the best Of my knowledge and bellBf, andUlat I haw not knowingly or Intentionally pnr.rIded or amll8d any fnfonnatiCln that would tsnd to hide, obscun" or otIIenvise mislllad the Depar1ment of ConnunJty Services ntgardlng the truth at the maUlDns ad'" _ssad Glerel/\. Further, I assert 1Iult I am the prvparty awner, or UIe authorized and IlIWfuUy appolnfBd lIgent of the GWII8I{8), that I haw 8XpNSS aufIlority and PermJsslDn frDrn the CNmer(SJ (and anyone wllh a . reconted InIeRlllt or other Intlmtst in the property), to tl,lke tide nKJU8SI8d utIon, and that I agree to Indemnllif and hold harmless tile City of ClImtrA fnIm ..y claim. lawsuit. demand. or damages WhaI8..."". arfsfng out of, or 118 a ~ 01', thl9 r&qUDSt Dr 1ft. actions of the City of Carmel, nlg8nIInUl5illlle. Applicant's SlgJIlItI.n & Date 1<14- ~~ (Name prfhllBd) tlerls ~tJL e.P. Applicant's Adell T 2,,- ;er:,Q/l 'S/7- b ;tJ~3'6S- Apptk:ants Phone # ~N.A City, :nq ST ~~ Zip STATE OF INDIANA ) SS Cauntyaf ) Before 1Ile,1he Und8l'51gned, a NaI:ilIY Public tal' appeared ~, SIato or indiana, personally 8IlId aclc>ouoftedged tho IIX8CQtlon oflhe f\..~g .20__ in8trument this day or N-,.PulIIIc MjCo.,_ . . .~ ll'IlttI) s-~ p&ItNlllonclout zorz ~~~J. "TOWNE SITE LOCATION MAP r II ~I ~I .. -. II [I -- - II ~ II -- III -- II II - _ , . ! ' ~ T , . ,~'~ ~, TCAIC ,\r f1(Cd nl,l,111kr Il-D,\-33-00-ou'-OB.cDD ~~.~. SITE LOCATION MAP r '., \ ~ ,( . ...... J' ,.C . -"\' .~~ .~ . .. Tc.<..o( (Y14.f fc:-rcel V1v~e.-( \7-01- ~~-OO.- 00-. DZ"3 ,0<::><.:) t, ' . , Signature: John Mascari (or representative) Date Signature: Barry McNulty (or representative) Date CERTIFICATE OF AUTHORITY Under the penalties of perjury (Indiana Code 35-44-2-1), I hereby affirm, under oath, that all of the information I have provided in this application for demolition permit is true and accurate, to t~e best of my knowledge and belief, and that I have not knowingly or intentionally provided or i omitted any information that would tend to hide, obscure, or otherwise mislead the Department of Community Services regarding the truth of the matters addressed therein. Further, I assert that I am the property owner, or the authorized and lawfully appointed agent of the owner(s), that I have express authority and permission from the owner(s) (and anyone with a recorded interest or other interest in the property), to take this requested action, and that I agree to indemnify and hold harmless the City of Carmel from any claim, lawsuit, demand, or damages ~~vJ~ OtJ:'h" ~qu"'o,th. "lion. ~t:;:~C;." Applicant's Signature & Date Da~ 2c- If:, tftl1cu/' R,c- ~V\(."--V\ '317-~(Or3?:'0J (Name printed) Applicants Phone # ! 1'1 /3 louJtVL d. Applicant's Address Co-r~ City, 111 ST If b:J3z Zip STATE OF INDIANA ) '1':'1 . 55 County of ~~ I Before me, the undersigned, a Notary Public for/~' County, State of Indiana, personaily appeared instrument this /3 day of V~#~~ Notary Public . If) Y///NC{j' j,VcJ/L- and acknowledged the execution of the foregoing ,20.1.2 ~O b'//P/?CJ? My Commission Expires: (Print) S:PeffilitsJFormslOemolition peffilit handout 2012