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HomeMy WebLinkAbout05110004-Signed Demo10/28z2005 15:00 F^× ~177788506 ~ CO HEALTt' DEPT 25~05/0~721/!;!~I 04'.2~ PM P~/~:ON ¢O~I~ FAX No. 317 577 9319 [~002 001/002 Demolition Permit.Requirements City of' Carmel I Clay Township Bu~ling & Oocle Enforcement; City of Carmel One Clvlc~luare; Carmel. IN 460~2 Ph. (317) 671-2444 Fax (3t7) 671-2499 location map, clearly the parcel on whioh the demolition Is to o~r, ur, and this form signed b,y. the approp, riato departments. (*Application Is a three-part form available from f~e Braiding & Case Enforcement Office) A separate permit application must b.e compl?ted per parc, el. certeln inspections am required relating to private wells, septic systems. and fuel , tanks, prior to demolition. · Shou d approvals be required from other State or local government entities, or utilities (other than those addressed herein), It Is the sole responsibility of the contractor of reoord to obtziin such approvals. to Well Ordinance A-62. or removed. If septic system Is to be mused plugged off until ready for m~se, Fuel Tetiks~ ~.. Fuel tanks ·must be pumped and removed from building andfor property.. · Address ef demoJl~loll 'Tax Map'Par~[ # prirn~r~ The C..~.. of Carr~el and/or Hamilton County Health Dept, must perform an inspec~lon prior, to demo~?_n,, In o~e. rto approve the demolfflOn permit, the eppllcent Is req_ui~, . to =lgn thfs forxn ando -'~fth le _div '-_ .: t - -_ · . (Tl~lscanbedOnehyFAJ~tofhelr offi~d belew) Include thls ~-omple~d form ~ THE REVERSE OF THIS PAGE) when you ~ubmit },our application package. t 3177768506 HAM CO HEALT~ 3EPT 2005/0C?/2t/FR[ 04;21 PM P,~AGON COMP~Ig$ FKX No. 317 577.9919 ~ 003 ?. 002/002 Date CERTIFICATE OF AUTHORITY Further, I assert th~ I am the property owner, or the authorized mid lawfully apl~inted agent me ~=), ~t I h~ ~p~ a~o~ and ~lon ~ ~e ~r(s}. (~d a?y~;~ ~r~d In~st or ~er in~t m ~e ~, m ~ mm ~ue~ .~on, an~ m~ I ~g~ to Ind~n~ and hold h~s ~e C~ ~ ~! ~ any =la~, la~u~ d~a, or ~a~ ~v~ ~slng out of, or ~ a ~uR off ~ ~u~ or ~e a~ons ~ the C~ ~ C~el. regarding 9em~e. FAX 3177768506 HA~ CO HEALTH DEPT ~001 HAMILTON COUNTY HEALTH DEPT. ONE HAMILTON COUN~ SQUARE SUITE 30 NOBLESVI LLE, INDIANA 46060-2229 PHONE: 3t7.776~8500 FAX: 3t 7-776-8506 NAME: GC COMMENTS-, . _ IF YOU DO NOT REOEIVE ~ THE PAGF.~w Iq~J~;E ~ BACK A~ SOON AS POSSIBLE CONFIDENTIALITY NOTICE The documents aCcompanying this tele~l~ trafmmissioa contain confidential ~ Is Intended only for the uss of the inividual(s) that not telel, bene at 317-7T6-8500 ~ 10/27~2005 08:28 3175';12265 2085/OCT/21/FRI 04',20 Pll PARAGON C~ANIES CARMEL UTILITIES ~X ~. ~17 577 9~i9 PAGE 02/03 P. Demolition Permit.Requirements City of Carmel / Clay Township Built, lng & Code Enforcement; City o~ Carmel One Civb 8cluere: CamleL tN 46032 Ph. (3'17) 57'~-244~ Fax (317) 571-2499 TO BE SUBMITTEd*.: Two copies of a site location map. clearly identifying the structure or structures to be demolished, the Tax Map parcel number for the parcel on whi¢;h the demolition is to occur, and this form signed by the appropriate departments. (*Applies#on is a three-part form available from the Building & Code Enforcement NOTE: 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 pr local govemme,n,t,entities, or utiIifie.<: (ot~er than those addressed herein), it is the sole resoons~b~lity of tile contra,.-~or of record to obtain such approvals. ~ · 'Well must be plugged according to Well Ordinance A-62. Ex~_s#n~ .Septic system must be pumped and filled with sand, or removed. If septic ~;ystem is to be reuses, it must be plugged off until ready for re-..u,.s.e. ;=ue! tanks mu~ be pumped and removed from building and/or prope~y. Tax Map Pa~l # Fuel Tanks: . Address' of demolff~n Owner(s) Name and Address AdditionalStructure(s) off site; Yes / No . '(if ybs, ;3 ease list the,n,~m~er an.d-ty~.e(~)'of structure on the'lines; provided, lfone'of the structures ha~s a separate; street addres~'tl~an the' primary structure on r~he parcel--please also include that information.) The C i~ of Carmel a nc//or Hamilton Coun?, Health Dept. mus~ perform an inspecgon p#or. to demoii#on. In order[) approve the demolition per/nfl, the epplicant is required ~o sfgn this form and~atu~e~.d -."._ted bel(~. (TMs can be d~ne by FA~. ~o their offices, a~ the num~~th;s com~e~d form with'all a :~o- r/ate (ON TH ! REVERSE OF r ls AaE) when sUbmit y ur application package. ~t P ~'n~'t s~D e m o~;:~ ~en'nl~ hand 3ut- (3~7) 776.8506. Morr~s CARMEL UTILITIES FA~ Ho, 3i? 577 9319 Date PAGE 03/03 P. 002 Date CERTIFICATE OF AUTHORITY Under the penalties of perjury (Indiana Coda 35-44-2-1),: I hereby affirm, under o. ath, that a!l of. the informatio~t I have ;ro~lded in this application for demolition permit is true aha accuram, m the be~.t of my kn°Wle~ll].e and belief, and that I have not knowingly or intenfi?nally provided ar omitted any information that would tend to hide, obscure, or otherwise mislead the Department of Community Services regarding the truth of the mattem addressed therein, properly owner, or the authorized and lawfully appointed agent of Further, I assert thai: I am the . the owner(a), that I have e~.press authority and permiss?n from the ~n.er(s?. (and a .r~_on.e. wltha reoorded interest or other interest in the property), to take this requestea acaon, ana mat I agree to indemnify and hold harmless the City of .C..armel from any olaim, lawsuit, demand, or damages whatsoever arising out of, or as a result of, th,s request Or the actions of the City of Carmel, regarding same. (Name printed) Applicants Phone # C~, ST Zip STATE OF INDIANA ) s County of ~A/'$~ Befere me, the unden;igned, a Notary P and acknowledged the execution of the f~regoing ~Pem~l~l[llo~ 0ermit hanlout 20f2 CARMEL UTILITIES P~GE 01/03 760 3RD AVENUE $.W. ST~. 110 · CARMEL, INDIANA46032 (317) 571-244..1 . FAX t'317' 571-2285 ~U~e~ L-I F~r Review [] Please Comment [] Please Reply [] Please Recycle Cgn~dentlall~ Noll~.: ]~ ma~,nal~.en~os~ w~h th~ facs~'~e trar~n~n are pm~ate an~ con~en~Ja ancJ am ~e I:~pe~ ~1 ~ sender, T~ ln~Oftllall;~n ~lned In file mat~4al Is p~leged and Is trll~n¢Jed only ~r iha use of ~e In~M~u~($) or ~nltb,.(lee) n~med above. Ir you are ~ot the Intended n~ptent, be advised Ihat any unauff~ortzecl dtsclaeum, co~ng, di~lbuJon or ~ne laking of any ad, on in reliance on the oon~nls of Ihl~ I~lecopled infonta~on is s~'lctly prohibited. If you have moaned th~s la,sirras tansml~ion In error, pl~se Immec~late~y ncf~y us by lelsphone to arrange ~o~the tatum ofth~ fomarded dom,~nenJs to us