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Home My WebLink About193719 01/19/2011 CITY OF CARMEL, INDIANA VENDOR: 074600 Page 1 of 1 ONE CIVIC SQUARE DEPT OF NATURAL RESOURCES CHECK AMOUNT: $200.00 CARMEL, INDIANA 46032 DIVISION OF WATER 402 W WASHINGTON ST W264 CHECK NUMBER: 193719 INDIANAPOLIS IN 46204 CHECK DATE: 111912011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 54439 200.00 MISC EXP- SOURCE OF SU NJ p •T4t• fL ej APPLICATION FOR WATER WELL PUMP Return to: INDIANA DEPARTMENT OF NATURAL RESOURCES I;< INSTALLED LICENSE DIVISION OF WATER f State Form 54439 (11 -10) 402 W. Washington St., Room W264 Approved by Slate Board of Accounts, 2010 Indianapolis, IN 46204 -2641 The provisions of IC 25 -39 require anyone who engages in the installation or repair of water well pumps in Indiana to have a valid Indiana Water Well Pump Installer License. To qualify for an Indiana well driller or pump installer license, an applicant must be at least eighteen (18) years of age, successfully complete a competency examination, and provide three reference statements to the Division of Water. At least two of the statements must be from licensed water well drillers, licensed pump installers, or licensed plumbing contractors familiar with the applicant's work experience and professional competency ff (IC 25- 39 -3 -3). Full Name: alb n �0 n a s CCc (First) (Middle) J (Last) Address of Business: _3 5 0 W T AJ_ (Street or Rural Route) (City) (State) (Zip) Office Telephone Number. r7 33 33 2 Email Address: S ��1,K� f' (o V (Include area code) Date of Birth: (mon� year) Type(s) of Pump Installation Equipment Installed: Number of Years as a Pump Installer: Employment History (as a pump installer): Name of Company Address of Company Dates of Employment _�5q 0 0 P0s4- P Q 90 0 /1 zoG 314.fn w 1 2002- The annual fee for a pump installer license is one hundred dollars ($100) for a calendar year. Please make your check or money order payable to the DEPARTMENT OF NATURAL RESOURCES (or simply DNR). I hereby swear or affirm under the penalties for perjury that the information submitted herewith is, to the best of my knowledge and belief, true, accurate, and complete. Signature: Date (month, day, year): %2 z! O Name of Company: L i t L r/VW_ Note: An application for an original license is not complete until three (3) reference statements are completed and received by the Division of Water. FOR ADMINISTRATIVE USE ONLY Date Application Was Received: Application Number: License Number Issued: Issued By: REFERENCE STATEMENT FOR INDIANA DEPARTMENT OF NATURAL RESOURCES WATER WELL DRILLING OR DIVISION OF WATER 402 W. Washington St., Room W264 PUMP INSTALLER LICENSE Indianapolis, IN 46204 State Form 42143 (R 1 11 -10) Mail the completed statement to the address above. To qualify for an Indiana water well driller or pump installer license, an applicant must be at least eighteen (18) years of age, successfully complete the competency exam, and provide three (3) reference statements to the Division of Water. At least two of the statements must be from licensed water well drillers, licensed pump installers, or licensed plumbing contractors familiar with the applicant's work experience and professional competency (tC 25- 39 -3 -3). An applicant may not act as hi or her own reference. Name of Applicant v ��Q 7 �S e- 4 r Street Address or Box Number �J Cily, State and ZIP code 1. 1 have known the applicant for O years. 2. My knowledge of the applicant's work history as it relates to: well drilling or pump installation f Pease D be /�(A Je �v 1 (t?v`. C ✓1 1� I L VGA�G P L� C- le- e 4* 3. My general evaluation of the applicant's professional competency- S �e LC wc3 Ds4-- I hereby swear or affirm under the penalties for perjury that the information submitted herewith is, to the best of my knowledge and belief, true, accurate, and complete. Signature o eference Occupation Printed Name of Reference License Number (well driller, plumber, pump installer) 3Y s "Vt/ „/,3 U �3 i 2 2.3 3 dZ Street Address or Box No. Telephone Number City, State and ZIP code ate of Statement (month, day, year) 01/11/2011 13:58 317 892 -2101 C &J WELL DRILLING PAGE 02/05 DEC.27.201A v9:03 3177332053 Carmel utilit.ios #V99 P.002 1005 REFERENCE STATEMENT FOR a mrimmA DFAARTME rs: NYTI.IRQL RGSQURCFS WATER WELL QRILLING OR wv+sloW 402 w. Vu shingwn St, Room W754 PUMP INSTALLER LICENSE Indianapolis, IN 46204 Stoic Form 42143 {R 1 11.101 Mail the completed statement to the acfamss above, 10 quality Tor an Indiana water well driller or pump installer license, an applicant must be at least eighteen (18) years of age, successfully complete the competency exam, and provide three (3) reference statements to the Division of WpWr, At least two of the statements must be from licensed water well drillers, licensed pump installers, or licensed plumbing contractors famlllar with the applicant's work experience and professional eompatency (IC 25 39 -3)_ An applicant may not act as his or her own reference_ Name of Applicant �-J c�/ r H9� Q 4 i Street Apdrfts or Box Number 7 Lc S Cuy, $late and ZIP code Cla- r ry-e I I have Known the applicant for years- 2, My Knowledge of the applicant'c work hi*tory as it relates to, wall dn or pump instellation Please f DesMQ- T I,u -A� (l_ 3. My general evaluation or the applicant's professloilal competency—• I hereby swear or aNlrrn under the penalties for perjury that the mtormation submitted herewith is, to the best of my knowledge elief, true, accurate, and complete. Sfgneture or rofere a O aA-n& C -Y=/ Panted Name of Reference License Numtrer (-fl driller, plumber, pump tnstalreq L P, r reet Address or Sex No. I TelepAone Nvmber Gty, and ZZJP cc e l 1 I Dare o cement (monrl day, yeeo l 01/11/2011 13:58 317 892 -2101 C &J WELL DRILLING PAGE 04/05 DEC.27.2010 D9:04 3177332353 Carmel Utilities #6799 P.003 /305 REFERENCE STATEMENT FOR INDIANA DEPARTWISIT OF NATURAL RESPVRCEs D 4*h1n N OF 1, Roc WATER WELL DRILLING OR 402 W. wyyhlnpto� St., Rcom w28a PUMP INSTALLER LICENSE u,dienepolis, I N 40 204 Stye r'arm 4.x 10.7 (R 11- i v7 Mail the completec statement to me avar*ss 90ove. To Quality for an Indiana water well driller or pump installer license, an applicant must be at least eighteen (10) years of age, successfully complete the competency exam, and provide three (3) reference statements to the Division of VVater. At least two of the statements must be from licensed water well drillers, licensed pump installers, or lirorsed plumbing contractors familiar with the applicant's work experience and professional Competency (10 2,5 39 3 -3)- An applicant may not act as his or her own reference. Name of Applicant 10 4. 6) -N Y S r" f Street Address yr Box Number J r City. State and ZIP cede �r' 'R f.✓ fs ca '7 S I nave Known the applicant for year's. 2. My kr,vWl go of the applica work history as it relate* to: wCU drilling or pump ;nstoltatior X Des Des 3- My genet evaluation of Ine applicant's professional rripetency h ®roby swear or arMrm under the penalties for perjury that the information submitted herewith is, to tine best of my '►ledge ana belief, true, accurate, and complete- ra R rence p =patron �arpnce Licerkse Number rvM0 dlilfer, ptvmoer pump installer) r, 1,ir4 Telephone Number t eorto pare of Statement (month, day, yssl a g APPLICATION FOR WATER WELL PUMP Return to: n INSTALLER LICENSE INDIANA DEPARTMENT D ISION OF WATER RESOURCES State Form 54439 (11 -10) 402 W. Washington St., Room W264 eie Approved by State Board of Accounts, 2010 Indianapolis, IN 46204 -2641 The provisions of IC 25 -39 require anyone who engages in the installation or repair of water well pumps in Indiana to have a valid Indiana Water Well Pump Installer License. To qualify for an Indiana well driller or pump installer license, an applicant must be at least eighteen (18) years of age, successfully complete a competency examination, and provide three reference statements to the Division of Water. At least two of the statements must be from licensed water well drillers, licensed pump installers, or licensed plumbing contractors familiar with the applicant's work experience and professional competency (IC 25- 39 -3 -3). Full Name: �5e/,i (First) (Middle) (Last) Address of Business: 5450 S� (St or Rural Route) (City) (State) n (Z i l p) Office Telephone Number -2 7 .33- Z eS Email Address: (Include area code) Date of Birth: (month, day. year) Type(s) of Pump Installation Equipment Installed: n�r_e UL/ G�, /�i�� J G��iJb/r►fL�Si�� Number of Years as a Pump Installer: //euiS Employment History (as a pump installer): Name of Company Address of Company Dates of Employment L1 6 dF d 4Ao9G/ .3 i W .F/ I r s/ LG✓.a►rEl oP& /Jr�SCrl The annual fee for a pump installer license is one hundred dollars ($100) for a calendar year. Please make your check or money order payable to the DEPARTMENT OF NATURAL RESOURCES (or simply DNR). I hereby swear or affirm under the penalties for perjury that the information submitted herewith is, to the best of my knowledge and belief, true, accurate, and complete. Signature: Date (month, day, year): Z-0 o Name of Company: Note: An application for an original license is not complete until three (3) reference statements are completed and received by the Division of Water. FOR ADMINISTRATIVE USE ONLY Date Application Was Received: Application Number: License Number Issued: Issued By: 01/11/2011 13:58 317 892 -2101 C &J WELL DRILLING PAGE 03/05 D3C•27.2010 04;04 3177332053 Carnal Utilities #6799 F.004 /005 REFERENCE ST ATEMENT FO TNn }ANA DEPA OF HATWRAL RCSOV WATER WELL DRILLING OR DMSIONOFWA2rA PUMP INSTALLER LICENSE 4 0 2 W Waching"11 SL. Repm Va State Form 421141 M 11.101 I"ls ^Rpofle, IN 46204 Mail the M- MP4I statement to the ec%fmss above, To quafO an lndiane water well driller vi purrep installer Ilcense, an apphpant must be at least eighteen (1a) years of age, successfully complete the competency exam, and provide three (3) reference statements to the Division of water. At least two of the statements must be from licensed water well driifers, foensed pumc inataticra, or licensed plumbing aoritraetors tam illar with the applicants work experience and professlonal competency VC 25-39 -3 -3), An applicant may not act as his or her own reference. Hams or Applicant n Street Address or Box Numlgr S-O Ck y, StaeQ and ZIP corio 1. 1 have known the applicant for 2 years. 2. My knowledge of the applicant's work history a$ it relates to: well drilling—OL or primer installation Please Oeacsbe h�� iwlo,f �i CG�nn cJ 171 T T`l1/Nl� Ci Co�..i 3. My general evaluation of the applicamt's professional Cvmpetcncy J her®bY swear or affirm udder the penalties for peritJrY that the infnrmation submitted herewith is, to the best of (ny knowledge anew belie true, accurate, and complete. SigridFtue Ol a eretrce w C (1 9oruperion P7AtA cr Ndme o(Rererence Lkense Number wellCril/er, y Plum pump 117SC8uRr) 1 L i 7,, Shovel'Add'ness w aw Nm I I l �n relepRorm Number \JF rr� ci.� a;v iir cup 1 Derr v 3 tnrarmm tlay, year 01/11/2011 13:58 317- 892--2101 C &J WELL DRILLING PAGE 05/05 DEC.27.2010 09:09 3177332053 Carmsi Utiiitics #6799 P.QQ$ /005 REFERENCE STATEMENT FOR IN171AKA pEFAR pF NATVRA REsWjtCF3 WATER WELL DRI LLING OR DMs 30N OF WATER. PUMP INSTALLER LICENSE 402 w ind anspolis, S 413n BiAle Fpm, 427 43 (R! s l 7o) M8i! the Completed statemen(to the address above. To qualify for an Indiana water well driller or pump installer license, an applicant must be at least eighteen (i s) Years of age, successfully complete the competency exam, and provide three (3) reference statements to the Division of Water, At least two of the statements must be from licensed water well drillers, licensed pump installers, Or licensed plumbing contractors familiar with the applicant's work 4axppriPnrP and professional competency (1C 25 An appllcaM may not act as his or her own reference. Name of Applicant Sireef Aukitres nr Ror Nvrn"r City, state and ZIP code ,ark Ord 7 1- I have known the applicant for years, 2. My knowfedge of the applicant's work history as it relates to: wefl drilling or pump installatiot? Please Describe V 11 JJ r �l 3. My general evaluation of the applicant's professional co petency— a rl b wear or affirm under the pertafties for perjury that the information submitted herewlth is, to the best of knpwl .and boilef, true, Accurate, and complete, r slgn� OFRL" nc� OCC w atiou l t win Neff* of Reftrtr.vc cnense N u griller, pium0er, pump rnSraller� 1 `7 t o f AOdrem ar qt< No. Telephone Nor nber 1 U 01f, Staft *Rd ZIP code 4 I Date of rr> StAlegnf (firvnth, day, yestj t y} A REFERENCE STATEMENT FOR INDIANA DEPARTMENT OF NATURAL RESOURCES WATER WELL DRILLING OR DIVISION OF WATER 402 W. Washington St., Room W264 PUMP INSTALLER LICENSE Indianapolis, IN 46204 State Form 42143 (R 1 11 -10) Mail the completed statement to the address above. To qualify for an Indiana water well driller or pump installer license, an applicant must be at least eighteen (18) years of age, successfully complete the competency exam, and provide three (3) reference statements to the Division of Water. At least two of the statements must be from licensed water well drillers, licensed pump installers, or licensed plumbing contractors familiar with the applicant's work experience and professional competency (IC 25- 39 -3 -3). An applicant may no act as his or her own reference Name of Applicant �/1C 7, edO/� Street Address or Box Number s7 t) T SA City, State and ZIP code e 7 7' 1. 1 have known the applicant for 8 years. 2. My knowledge of the applicant's work history as it relates to: well drilling or pump installation Please M�Je J tnL �i 1/ e `F �`e Describe 2 f c ,r m e 1 e ✓1 1 i) V e 1 U c- e, do n ✓Vt( 15 3. My general evaluation of the applicant's professional competency— DS L I hereby swear or affirm under the penalties for perjury that the information submitted herewith is, to the best of my knowledge and belief, true, accurate, and complete. Signature of Reference Occupation 14;�Q L4' "4A� y Printed Name of Reference License Number (well driller, plumber, pump installer) Street Address or Box No. Telephone Number City, State and ZIP code 'Date of Statement (month, day, year) VOUCHER 103849 WARRANT ALLOWED 74600 IN SUM OF DEPT OF NATURAL RESOURCES DIVISION OF WATER 402 W WASHINGTON ST W264 WA INDIANAPOLIS, IN 46204 -2641 Opp Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO INV ACCT AMOUNT Audit Trail Code 54439 01- 6750 -02 $200.00 Voucher Total $200.00 Cost distribution ledger classification if claim paid under vehicle highway fund Prescribed by State Board of Accounts City Form No. 201 (Rev 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show, kind of service, where performed, dates of service rendered, by whom, rates per day, number of units, price per unit, etc. Payee 74600 DEPT OF NATURAL RESOURCES Purchase Order No. DIVISION OF WATER Terms 402 W WASHINGTON ST W264 Due Date 1/1212011 INDIANAPOLIS, IN 46204 -2641 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 1/12/2011 54439 $200.00 I hereby certify that the attached invoice(s), or bill(s) is (are) true and orrect and I have audited same in accordance with IC 5- 11- 10 -1.6 Date Officer