HomeMy WebLinkAbout05090022-Signed demo~ 09/0~/2005 12:00 3175712265 CARMEL U¥ILITIES PAGE 02/02
~ep O! 05 12:5~p ~t~ven SPillmm
( :! Demolition Permit Requirements
t,..~. City of Carmel / Clay Township
~..~f~.. ~ Build,n§ & Code Enforcement; City of Cerrne~
One Civic Square; Carmel_ IN 46032 Ph, (317 57%2444 -'ax (317} 671~249g
~3 WITH APPLiCATiON*: Two copies of a site location map-clearly
entifying the stnmture or structures to be demolished, the Tax Map parcel number for
the parcel on which the demoJitlon is to occur, and this form signed by the appropriate
departments. (*Application is a three.pal~ form available from the Building & Code
Enforcement Offic ?)
NOTE:
A sepa *ate permit application must be completed per parcel
* Certain ms~ections are required relating to private wells, sea)tic systems, and fuel
tanks, prior to demolition.
· Should approvals be reouired from other State or local government entities, or
utilities 'other than those addressed herein), it is the sole resoonsibiiity of the
contrac"or of record to obtain such approvals.
~ Well must be plugged according to Well Ordinance A-62. /2 ~1~ [
~ Septic system must be pumped and filled with sand, or removed.
system is to be reused, it must be plugged off until ready for re-use.
Fuel Tanks_: F,zel tanks must be pumped and removed from building and/or property~
~ ddr~.e~ of d~moliEon
. .......
Additional Struc~ure(~) on sit~ I No (If yes, Ptease list the ~rnber and type s of
st.ructure on the Ifnes provided. ~-orf~f the structures has a separate street address than th
primary structure on ~ )
[h'-~ parcel~please also incfuee that informa[ien.)
.. . ~prove the demolition permit, the a lieant i ' ? o ¢o
and obtain the si~nat~,res of th~ ~...~:..,~---,~ ,, ...... PP s required to s~gn this
' - u~ ~,,=. YUU~u~m/~yourapp/ication package.
0 '
~. M mS Hensley, Supe~isor: Water T~atment Ope~tions, Ci~ of Carmel;
Phone (3~7) 571.2673. F~ (317) 57i.~ Z~
Z Ba~ McNul~: Hamif~n Coun~ Health Dept.;
Phone (317) 776.8500. F~ (3~7) 77~8506.
09/06/2005 12~00 3L75712260 CARNEL UTILITIES PAGE
~~ntative)
Date
CERTIFICATE OF AUTHORITY
Under the penalties of perjury (lndlana Code 35-44-2.1}, I hereby affirm, under oath, that all of the
information I have provided in this application for demo iff.on permit s tr,ue and accurate~ to the
bes. t of my knowledge and belief, and that I h.ave not knowingly or intentional y prov ded or
omitted a~ informatic,n 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
rec. orded interest or other interest in the property), to take this requested action and that I agree
to indemnify and hold harmless the CiW of Carmel from any claim, lawsuit, demand, or damages
whatsoever l ou: of, or as a result of, this request or the actions of the City of Carmel,
31icant's ~ignature & Date
Date
Applicants Phone #
Applicant's Address City, ST Zip
8:TATE OF INDIANA }
County of~D
Before me, the undemignod, a Notary Pubhc for ~- ...... ~Coun~, State of Indiana,
-~ 7~:'~/rc' "? r , and acknowle~ the execution of the foregoing
appeared
0~/07/2005 09:37 FAX 3177768506 H^M O0 HEALTH DEPT ~001/002
Se~l~ O? O50S~O?a St. even Slol]lm~- 3~[?-~E;-0~14
Demolition Permit Requirements
City of Carmel I Clay Township
% Building & C;~::te Enfor~me~t~ City of Carmel
One. Civic Square; Carmel IN 46032 Ph. (S17) b"71-2444 Fax (317) 571-2499
~ .IT APP' -_~- TION*: Two copies of a site location map-~learly
be demolished, the Tax Map parcel number for
the parcel on which; the demolition Is to ooour, end this form signed by t.he appropriate
departments. ~*Appllcation is · three-part form available from ~he Building & Code
EtlforCement Office)
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 ocal government entities, or
utilities (olher than those addressed herein), it is the sole responsibility of the
contractor of reoord [o obtain such approvals.
~ Well must be plugged according bo Well Ordinance A-62.
~ Septic system must be pumped and filled w~th send, or removed, if septic
system [$ to be reused, It must be plugged off until ready for re-use.
~ Fuel tanks must be pumped and ~rnoved from building and/or property.
Owner(e;
Additional $~eture(s) o,n s~r~r~ / No (If yes, please list the number and type(s) of
structure on the lines provided. I1~:ltq~of the structures has a separate street address than the
primary structure on the parcel--please alSo include that information.)
and/or Hamilton ~oun~ Health Dept.
~ page) when ~/ou submit your application package.
M._orris Hen$1ey; .s~u~e~visor: Water Trea~f~nent Ope~ratlons, CI~y of Carmel;
Phone(317) $7q 2673. FAX (3f?)
Barry McN~;i~/: Hamil~on ~un~
Phone (31~ ~8500. F~
8t07/200 08:37 FAX 8177788508 H^H CO HEALTH DEP: ~002/002
' (or representative)
CERT~FICATE OF AUTHORITY
Under t~e penalties of perjury (Indisna Code 35~.4-2.1 ), I hereby a~..; ~m~, under oath, that ell of the
information i have proVld~d in this appllc~tion for demoll~km ~i~ is true and accurate, fo the
bes~ of my knowledge end belief, and that l.have not Imowlngly or Intentionally provided or
omitted any lnf0_ rmatlo~t that would tend to hide, obscura~ or other~vise mislead the Department
of Community ~erv~=as regarding the truth of the matters addraesed therein.
assert that I am the property owner, or the authorized and lawfully appointed agent of
~n~s), ~a~ ~i~l~ ~ t~ ~s) (~ anyone ~ a
~ = ~e C~ of C~ lei from any =l~i~, I~suit, d~d, or damag~
~ as a r~u~ of, this ~qu~t or
AppU~nts Phone
Applican Zip
STAT~ OF IND~A~A )
Before me, ~ un¢h~r, igna~ a Notary Pubilc for ~~unty' ~ of Indiana, p~rson;~lly