HomeMy WebLinkAbout05090006-Signed Demo Building & Code Enforcement; City of Carmel
One Civic Sauare; Carmel, IN 46032 Ph. (317) 571-2444 Fax (317) 571-2499
TO BE SUBMITTED WITH APPLICATION*
Enforcement Office)
NOTE.:
Fuel Tanks:
ocation map--clearly
Tax Map parcel number for
~riate
; Code
~st be comp eted per parce
ns are required relating to private wells, septic systems, and fuel
.mohtlon.
), it is the sole res
to obtain such approvals.
Well must be plugged according to Well Ordinance A-62.
d filled with sand, or removed. If septic
syster Jgged off until ready for re-use.
Fuel tanks must be pumped and removed from building and/or property.
/ No (If yes,
ist the number and type(s) of
; street address tha~ th~
08/26/2005 09:32 FA× 3177768506 H^~ CO HEALTH DEPT ~003
^u=,25, 2005 9:09~PM wt ENGINEERING No, 1743 P. 2
Demolition Permit Requirements
City of Carmel / Clay Township
Qne OMO 8qua~; GmmeJ, IN ~ Ph, ($17) 57t-244~ Fa~ (317] 571-2499
~DWI =-'"-.- _ __TION*: Twoeoplesofamitelocaflonmap..~leari¥
· be demoli~shed, the Tax Map pamel rlumber for
the pares*on whlOh the demolitmn Is to ore, ur, and this form signed bythe appropriate
d_ep~b'tmenta. (*..App. lication is a'three.part f~/:m available from me Bu~/dlng ~ Co're
enforcement
A sepam, te permit application must be ~ompieted per pamel,.
Certain ~nspectl~ns a~e required relating to priVate wells, septf~ systems, and fuel
~nk:~, prior to demolition,
Should,.approvals be required from other State or local government entities, or
'utlllties~(other than tho~o addressed herein), It Is the sole responsibility of the
contractor of record to obtain suoh approvals.
Well must be plugged aooordlng~to Well O~cllnallCe A-62.
system must be pumped and filled with sand, or removed. *If septic
s~stem la to be reused, It mList be plugged off until ready for re-use.
~uel tanks must be pumped and rem?~ved from budding ~and/or prope, rty..
Tax Map Parr, el #
e~ldress'
, ruoture(s)
No (If yes, please list the number and type(s) of
si s I~ !s a separate street address than ~e '
Include that mfom~atlon,)
The C..~.. of .Care? a. neYor Ham/Eon .Coup.?. Hesllh Dept, .rnu~ perform en mspecUon prior to
~nerures (ON THE REVERSE OFI'HIS PA GE~ when you submit yo~;~~ckeg~
08/28/2005 08:33 Fl× 8177788508 HAM CO HEALTH ]EPT ~0o~
Aug, 2~. 2005 3:1OPM W T ENGINEERING P. 3
No 1743
Date
CERTIFICATE OF AUTHORITY'
under oath, that all oftha
md aoourate, to ~e
I or
or otherwlae mlalead the Department
of Community Ser,,~Ice$ regarding the truth of the matters addressed therein.
.F. urth.er, I .a??rt that I am the property _e,fmer~ or the authorized and lawfully appointed agent of
me o .w~...r?.), mat I ha.v.e eX.p.ress .a.utl?orlty and pe. rmlaalon from the owner(a) (and an~mn~ with a
recomee l.n. terest or omar ;nmrest ;n the property), to take this requested action, and ~at I agree
tQ Indemnify and hold harmless the City of Carmel from any claim, lawsuit, demand, or damages
what~?ver arising out of, or aa a re~ul~ of, this request or ~he aoti0ns of the City of Carmel,
regarding same,
· Date
Applicants Phone
ST Zip
Before me, the undersigned, a Notary Public for Da (C Courgy, ~e ~ pemonel~
~r ;~ and ao~ow]~ged the ~c~on ~f ~e fomgo]n~
~n~ment ml~ ~ d~ - -.
2of2
CARHEL UTILITIES
~o. 1727
PAGE 02/03
P. 2/~
the
departmsnt~.
Requirements._.
City of Carmel ! Clay Township
~'dlng & C~:~e En'~rCemen~; Clt~of Ceffme~
One C~S~ ~e;, IN ~2 Ph, (317] ~1-2~ F~ ~17] 571~
Two copies of a site location map. clearly
, the Tax Map parcel number for
ooour, and this form signed by the
appropdate
from ff3e Building & Code
~eSepa~te perm~ application must be completed per pamel,
rtatn ~nspections are required relating to private wells, septfc systems, and fuel
o~er State or local government entities, or
it is the sole responsibil~ of the
contractor of record to obtain such approvals,
Well must be p{ugged ace=rdlng to Well Ordinance A.62.
Fuel tanks must be pumped and removed from building and/er property,
structure on the lines proWded...
(If yes, please list ,the number and type(s) of.
separate street address then the
.)
and/or/ ~ inspecEon prior
.fene by FAX ~o gleir
your eppliceEo~ package.
City of Carmel;
* 08~23/2005 00:06 3175712~65 CARMEL UTILITIES PAGE 83/03
Au~.22, 2005 I:02PM W- ENGINEERING No ~727 P 3/5
Date
. SJDnatum: Barry McNulty [errapresen~ti~e] Date
CERTIFICATE OF AUTHORITY
Un. der the penalt/es of perjury (indiana Code 35-44-2~i), I hereby affirm, under oath, that all oftbe
'!n~.rm.atlo~ i ha'? .provided in this app~leatte~, f~r demol/fion p~rrnlt Is true and ac~u~, to ~e
oe~?.my i?owledge and belief, and that I have not knowingly or intentionally orovided ~r
om~ne= any Information that wolJ~d tend to hide, obscure, or otherwise mle. lea~ t'he Del~l~ent
of Community Services regarding the truth of the matters addressed theme.
Further, I assert that ! a~n the property owner, or the authorized and lawfully appointed agent of
the o .wne..r(s.), that I have express authority and permission from the owner(e) (and anyone w~th a
.re~o .meet ??rest or other interest in the property), to take this requested action, and that ! agree
to n=emnny and hold harmless the City of .C.a. rmel from any ¢~alm.., lawsuit, demand, or damages
whatsoever arising out of, or as · result of, this request or the a~flons of the City of Carmel,
regarding same.
Date
Applicants Phone #
e~fom me, the
undersigned, a Notary Public for
~monally
_ and ackn~[ed~ ~ ~ecMion ef ~e foregoing
tn~me~ this~ d~ of 20
City, ST Zip
2~2 .