HomeMy WebLinkAbout04010064 Contractor Affidavit
City of Carmel
DEPARTMENT OF COMMUNITY SERVICES
AFFIDA VIT
To be signed by Property Owner(s) and Newly Assigned Contractor
Building Permit Number: o~ q 00<0 +
Permit Issue Date: ~~""L. O~
DATE: OC;-..}..(. of-
Notice is hereby given that ~~~e.( ~'Sfru..c.....fi ~....,
Previous Contractor's Name
above-referenced project and permit number, in whose name was issued for a
to be built at (cca01- ~ven- ~e,{ ·
Address of Construction
is no longer the responsible party for the
~.u. i .ftC:v\
Type of Construction
As of O~.".l..( ..04
Date
~ ~ Cc.- f-f- c>rt- on
.... New Contractor's Name
inspections will be performed and that the project will comply with, and conform to the Building Codes and Zoning
Ordinances of Carmel/Clay Township - 1980, adopted under the authority of Acts of 1979, Public Law 178 Sec. 1 et seq,
General Assembly of the State of Indiana, and all Acts amendatory thereto.
MG-r k- # 0 rl-o t1.
, responsibility for the completion of this project will be assumed by
, who hereby certifies by this Affidavit that any remaining building
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 Owner(s) Signature:
",^A-~ t4 oil- 'TO N
(Name)
L-y:f~ (Jr. l....t -. ocr
(Print) Date
~~\ ~ 4 (,0:5) (3(7 ) ~4~-2.S<t3
City ST Zip Phone Phone
(Print) Date
( )
City ST Zip Phone Phone
((1604 ~\I~~ r
Street Address
(Name)
Street Address
STATE OF INDIANA )
~ A"~"SS
County 0 )
~fore me, the undersigned, a Notary Public for /~ County, State of Indiana, personally appe,lred
~ 7 (l~ and acknowledged the execution of the foregoing instrument thisc-2 /' day of
L-y?~_ ~~.
/' "L , 20
~
/&t~{, ~/ ~,~/
Notary Public
(-fy (//<-1 C 0
(Print) ONE CIVIC SQUARE CARMEL, INDIANA 46032 317/571..2417
SEE REVERSE FOR NEWLY ASSIGNED CONTRACTOR INFORMATION & SIGNATURE...
?I/. Oc~k
My Commission Expires:
Contractor's Name (Assuming responsibility for project)
M-~.a&- t+or+~
',--
(Name of Company)
L--t2J. @."
O$~ 2(.. Ocr
Date
(Signature of Representative or Agent)
OA ILILU-.- +t c::tL-TD r-J
(Print)
((684 ~(U~~..
Street Address of Company
CckT"~. (
~
City
ST
4~(Po ,)~
'"V .,
Zip Phone
(.3(7 ) ~~1..\'1~
Phone
(
)
{ACtoFt-y (3 e cS _ udUY-
Email Address
FAX
STATE OF INDIANA )
SS
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:
(Print)
Rev. Oct. 2003
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ONE CI.VlC SQUARE CARMEL, INDIANA 46032 317/571,2400
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