HomeMy WebLinkAbout0139.03 Contractor Affidavit? ulty of Carmel?
P"+ co DEPARTN ENT CAF CONTMUNITY SFR ICES
AFFIDAVIT
DATE: - f - Buttding Permit Number: Z 603 ` C -
Iss-1;'A: 120 200 5
To be signed by Newly Assigned Contractor and Property Owner
Notice is hereby given that ((+ is no longer the responsible party for the
Previous Contractor's lame 20,0 -3
above-referenced project in whose name building permit # 0l-;476 was issued for a 9ES
l' Type of Construction
to be built at ?qa
Address
As of responsibility for the completion of this project will be assumed by
Date
iV 1A !-?AEGzo'-VeI- , who hereby certifies by this Affidavit that any remaining building
New Contractor's Name
inspections will be per>ormea and that the project wiii comply with, and conform io the Building Codes attd
Zoning Ordinances of Carmel/Clay Township - 1980, adopted under the authority of Acts of 1979, Public Law
178 Sec. I et seq, General Assembly of the State of hadiana, and all Acts amendatory thereto.
4't 14vlleelc&lue2 - certifies that the construction will not be used or occupied until a Certificate of
T New Contractor
Occupancy (CIO) has been issued by the Department of Community Services, Carmel, Indiana.
Prop t ?fvnler') tire:
(Name) Date
(Print)
(Name) (Date)
(Print') /? f I
Property Owner(s) Current Address & Telepbone
(TD be Notarized...see next page)
ONE CIVIC: SQUARE C:AKMEL, 1NL)1ANA 4602 i? 7;571-24 7
STATE OF INDIANA )
SS
County of % ?lG ,? ?o r) )
Before me, the undersigned, a Notary Public for County, State of Indiana, personally
appeared ('hCt t ID'S l? r ?? ?hc 5 and acknowledged the execution of the foregoing instrument
this day of l4-'i2 6
Print
My Commission Expires:
Contractor's Name (Assuming responsibility for project)
(Print )
(Doing Business As)
(Date)
Contractor's Address, Telephone # & Fax #:
STATE OF INDIANA )
SS
County of )
Before me, the undersigned, a Notary Public for
appeared
this day of
County, State of Indiana, personally
and acknowledged the execution of the foregoing instrument
20
Notary
My Commission Expires:
Print
Rev. Uri 2102
STerrilb AI i?avits'13ui1derAtTdavit