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 $.W. ST~. 110 · CARMEL, INDIANA46032
(317) 571-244..1 . FAX t'317' 571-2285
~U~e~
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~ sender, T~ ln~Oftllall;~n ~lned In file mat~4al Is p~leged and Is trll~n¢Jed only ~r iha use of ~e In~M~u~($) 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