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AFFIDAVITTO INDUCE INTERIM REMODEUNG RELEASE
AND/OR EARLY FOUNDATION RELEASE
CITY OF CARMEUCLAY TOWNSHIP
�ate: � —/'f - 9 7
8uilding Permtt No.:
Entity (Business or 1 � �
Individual): 8/n� k��z�-?—c�z��
Applicant-Affiant: G• m «'�� z-U 1�2,c.r�vr�
CC � ^ a _ �
Project Name: �cTn-11- �
- Address/Location: S SO �����_�y�� - �m d ���.e-��
� I, being duly sworn upon my oath, state the following:
1. I am executing this Affidavit for myself or as the authorized agent of the
above-referenced Entity to induce the City'of CatmeVClay Township ("DOCS") to allow me or the
Entlty to proceed with development pursuant to the Plans {defined betow).
2. That this A�davit shall bind me or said EnSty and any further reference to "I" herein shall
be considered as a reference to-me o� such Entity.
3. I have filed with the Office of the State Building Commissioner ("SBC") of the Indiana
DeparUnentpf Fre and Building Services for its review and approval, plans and specifications (the
"Plans") for development of the above-referenced project (the "ProjecY'), which 1 believe to be in .
compliance with all'State of_Indiana requirements including, butnot.limited to, the rules of the Fre
PrevenUon and Building Safety Commission,the Uniform Building Code, the NaUonal Electric Code,
the National Plumbing Code and the Model EnergyCode, alf as amended from time to time (the
"Rules").
4. I have presented to DOGS a copy of the Pians, and that any changes submitted to or
required by the S8C wiif6e submitted to DOC3 in a timely fashion and that the Plans stamped with
a final approval and accompanied by a Fuli Design Aeiease will be submitted to DOCS prior to
, scheduling"the final inspection and issuance of a Certificate of Occupancy (C!O).
5. I further understand that appiication for an interim remodeling release and/or early
foundation release will only allowme or the Entity, after payment of the full fee to DOCS, to proceed
at mylts own risk.
6. I understand that by proceeding on an interim basis, I accept responsibiliry for removing
and replacing any consVuction found by plan examina6on or by site inspection not to comply with
the Rules and/or those rules'and regulaUons of DOCS and/or ordinances of the City of CarmeVClay
Township.
� (�
7. I further acknowledge that I am proceeding on an interim basis at my/the Entity's own
risk and that I assume and accept all liability for the project and wilf indemnify and hold the City of
CarmeVClay Township, its officers, employees and agents, harmless from any and all liability to any
person o� entity (including the Entity), resulting from p�oceeding forward without a stamped set of
Plans and a Fuli Design Release from the SBC.
8. I further agree that I wiil pay the City of CarmeUClay Township for any and ail expenses,
inciuding reasonable attomeys fees;it might incur in taking enforcement action against the Project.
9. I further acknowledge that, in addition to the Ruies, I must compiy with all other rules
and regulations of the City of CarmeUClay Township and the State of Indiana as such relate to the
Project including, but not Iimited4o, buiiding codes and zoning ordinances as amended from time to
time.
DATED: _ �-/� - 9 �
� �� g� '
Signature
G, ,-n�"cti e f%� �✓
Printed Name
STATE OF INDIANA )
)SS:
COUNTY OF HAMILTON )
Personally appeared before me, a Notary Public, in and for `��z�-��n County, State of
Indiana, acknowiedged the execution of the foregoing Affidavit and indicated that the facts stated
therein are true. The Affiant furttier represented that he/she has proper authority and resolutions
to execute this Affidavit on behalf of the entity.
_•_ V�!i;ncss my hand and Notarial Seal this �7 day of d�_P�l-, , 19 �.
:-� � ' . _
�•: _
� , �' � c�r �� A -F �
�ru-cr�/
~' �- Notary Pubiic
,: _ ,�:
� ._. . �v� m • �Jh ;��=
Printed
My commission expires �� -�7' q 7
c:96docnum,1002.9hs/pg2
dg/tj/ghs
March 1996
1��"\ .ABPLICATION FOR CONSTRUCTION R"°'"''°
i��' DESIGN RELEASE P�nr� aeview oivisioN
Siat=Form.]T7ie(Ri2/6�96) OFFICE OF THE STATE BUILDING COMMIS90NER
����.-. ��' Approvedhy5ta�e8oardoiACCOUpls �996 �INDIANAGOVERNMENTCENTERSOUTH
402 4`/N/ASHINGTON ST RM E2d5
. _ � INDIANAPOUS IN 4620a
' � ❑
. . -. . . . .. -- _ � _. � i �
Under ih? provisions ol Indi2na Cede 22-15-3, plans. specilications. or changes Iherefo. Ier aIL Ciass t SUUCWr?s ' �o h? bu�it. added to.all?�ed. I
mov=C into or wlhin the State of Indiana. inGuding fadory bu�Ii struclures�and s�ie imp�ov?ments�. as such aflect access by Ihe phys:caliy �
handicapped, musl be submllted lo Ihe Stale�Builtling Commissoner lor a stalewide bu�lding ccde camp6ance r=•�le��belare cens�ruction begfns. �
THIS DOES NOT APPLY lo one and iwo IamBy dweilings.with Iheir appurrenanl si�uciures.nor ro builtlings bcaied on la�ms whkh are intended�o �
serve larming lurctions (nol indutling retad sales).�Local authoritie;.should be:consulted rogartling such structures-This Apofcaiion b�Construcew� ,
Des�gn Relezse must aaompany lhe submission and must be complele and legitiie-.�e0artmenl statl shouid he consuRed lor prxedures on I
remcdel projects,code variance requesls,+panial submissions.maseer plan approvals and manulacwred bulidings. �
"Class 7 Siructure"means any part of the bllowing: _
(�) Abu�lding or struclure'Ihat is�imended lo b?o�is occup�ed er.oiherNlse used in any part by any of th=Iollowing:
(A)7he pu6llc.(B)Three or more.tenants.(Cj One or morepersons who act as Ihe employ?es of anoNer.
� (Z) A sile impro�?menl aHecting access by the physically handicapped to�-a building or slrucWre described in t. 1
(3) Any class el�6uildings oa strucWresdhal�.the commission delermines by rules to aHecl a building or slruceure i
described in(1�,except buiidings a�d struc;ur=s in I.C.22-12,1�a subsections(c) Ihrough(e�.
i
� � ❑ • i � � I
� 1. Two Aoolications for Construction Design�Release longinai and one copy).eogetfier with correct liling L=es. (See le?scheCule.J �
2 7wo compleh seis et pizns and specifications.One set wiil be reNrned to tfie acplicant tor use a[Ihe job slte.Adollional collaled sets may be i
su6mitt_d and relumed if slamped sets.are�need=d'for other purposes. Pleasz limlClhe w?Igh!ol each submllLd package l0 30 pounds. '
A. Sile plan showing dimensicn=d location of buiiding toall preperty lines and to ail exis�ing buiitlings on[he property.as•aell as width ot �
i
any stre_ls or easements borderingihe propeny. .
B. FoundaUOn and basemenl plans and detaiis. 'I
i
C. O�msnsioned flocr pians Ior all Ilcors. � � �
D. Fire and life salery plan showing graphicaliy or by legend the Iocalion,and rating ol building elements such as area separation walls. I
smoke�barriers,fire-resislive corridor walls,stair enclosures,�shaft enciosures and horizontal exils.
-- E. NJall e!evations o�all.exterior wails including adjzceN�ground elevalion. �
E Secticns and delzils ol wzlis. Iloors and rool.showing tlimensions.mat=rials.�and heat�ransler facicrs (R-Values). '
G�. Structural pians and elevations showing size and locaiien o�all members,.iruss designs shoviing all connec;ion Cetaiis,and all siress i
calcWatiens.�t=p?cilically requested. '
H. Roem tinish schedule showing linishes br•.valls,ce�lings and floors in all rcoms.s�air.vzys and mciCors.
I. Door scheduie showing material,size.Ihickness and�-lire-resislive reling Ier all doors. .
J. Construclion specificalions (may be on plans for smallGre�ecfsJ.. .
K Electrical pians.diagrams,del2lls ol szrvice entrance,and power or lignt�ng inlormzeion required for energy conservation.
L Plumbing plz.^.s 5hewing IcCation of fizWreS, ��ser5.drains a�d piping i5ort:e!riCS. I
M. Mechanical plans showing localion and siz=ol duclwork,equipmem,lire dampers and smoke dampers and=4uipment schedules ;
i
showing czpzdty.
_ � �
� AREr�OR�COSY X FEES!UNIT — SUBTOTAL i
All mnsbuction Cocv�:eMS. ir.Gp�ding plans, sFecilications and 18 825 X = �
certilicates ieGU�red_tiy rhe Ger,eraiAdmrnlsfrafive Rules. 6751AC t2, X - ;
whiU ar?SUbmifted to th,e Staie 6uilding Commissioner purs�ar;(o X . _ '
I. G 27�15-3,.shan Ce acmmFa^�ed by paymen�fo the S�a�e Build�ng X = �
Commiss%oner Fund m an amount prescnbed by !he curren! tee X _ I
schecule. Make Checks,payable lo Ihe Sfa(e Building Commissioner SPECIAI FEES
Fund. (Specity Type) — i
Interim 70.00
BASIC FIIING,PE� = 4 �'
The c�rrenf le? sch?dule may be acCu'ved d�r=clly lrom Ihe Pian. - -� -�-- i
Re��ew Drvls+on or lhreugh your Iccal bwlding departmenl. The!ee '' �
schecule%s subjecf ro change once each calendar yeac � � � �- �' 773.88
❑ ❑ � � '
'T�¢loilo.vin9 suFpieme�ial aCC�Kaib�brms sliall De pro�ded whenihe spedal type ol i��ing cr re!ease is sougtii o�reGu�red.Re�er�o Icrmsand;ne 3^�e�al AEm�r,rstratne �
Rules�or Ivnner Cela��s C�Cali(J1 i)2^.2�1=71. I
PARTIQL FILING .. . ......TO�ie a Cw�G��C�SIruCIW e in pha5P5 SuG�d5 StruCNra�.Arc�t¢CU�dI.Ripc`aniCdl,pIc
�EqIM REMODEIING .P iows remeC?���g cansirucfiomto O�ccee0��inove a iui���eteas ,lmli=tl:o'9"cccvCanc:es remoeei���g. .
_ . I
EAIM�SPARIKLER...__......A��o'^5 sp�����er lnsla'��aGCn lo proce=C.:�mcaia��iW��e�eas .L�:+,IeC to�:q�t nazard (a�y s¢=J a�4.o�C��ary ha[3'd 1 or 2(�a+.2?"ea_^5•
rOUNDATION FELEASE..:._.. A��aws icucCaiien work.up lo grade.Inc'uG�sub�g�ade W�i�i;es,io p�cc=ed wl�noui a�u���e�ease ,
AO�ENOUM.................. Fe�oireE'.vt+en7ield cna�ges ar?planneC+�hKh motl�tyl�P pla�s O��SpEdIiCdlb�S�e�ed5¢d by I�¢O�wsGa . �
FIHE SUPPRESSION SVSTEM._..Requ'v¢tl when insialfng o�modi�ying a fre 5u0oressro��system. ' ;
FLAMMABLEANOCOIA9USTIBLE . � . �
tI0U1�5 ANO.GASES........._.Fequhed���en inslallingla�ks an0 tl5pe�s��g eQU�pme�i Ior tlammab�e ar.d com0usli��e I�qu�ds or gases ;
VARIANCES ..................Aequired when seekirg'avariance to lhe Nles ol.lhe'Fire;P�e�enlian arW Buildiig Salery Commissian. �
M Eaua�Oooano�.ry Emplore.:���a�.�a.suGwnee Siaie Agm<Y Pag?
fs,;2. CERTIFICATE OF COMPLIANGE , _ , �
ilo Oe complelad Dy suDmi(terl SdCprcjea wmbzr Flling tlate
� ��Pieas?inC�cal2 how you wish to�recerv?fne.desgn release and plans. �� -
'. � vJe .vai maii�o Ine tlevgn proiesvoral{ownerJno des�gn prcless�ona� ❑ titAIL - -
� . �
•�`'We vrlil cali ihe dzsi9n protessional(owner il no design prolessionaq . �[�] CALL FOR PICK-UP _ _ .
' • . .
I tia..��a Jt prc�eci . . . . - Cbsesi inlerseaingsrctet ar rcaC �
� Conseco GCC9 � � .� ,. �
� ;ecrzss(v:e+ocabon.numoer jr.p s�reap S�hi or,lico�p/app�caDleJ �DtrecGcn FROM inlersection TO pro�e<l
� 5�� Con ressional Blvd, artial� 2nd Fl�. ❑ Nanh ❑ So��h � Easi ❑ wes�
i Cd-i a�tl caun�y ' �" Is pro�ect wMin ciry limi�s?
' � Carmel,. Indiana� �HamilLOn .Gounty � ves ❑ No
_ _. _ a- a- � :. , - .
�a�c..ner ol ir.tpro�ac�lor�nn¢n thi5 appLCaGCi 2�Ee��ng�hled'I nereby:anJy: -
I7 ine tlescnpnon ol usz antl ir,lorma�ion conealned on�his�application are correci: .
2 ine pro�ea��.vill be constructed in accordance�with Ihe releas2d tlocuments andapplicable rules ol the Commisslon;
3 any cnangzs to !ne ieleasetl tl�uments will be�liletl with Ihe Otlice of Ihe Sia12�8uilding Commissioner. -
I a„mcn:etl z�gnature Name ol owner o/Dusiness
, Conseco Companies �
i rvamz�ryp2d or pnnra0) Address(number ar�tl sbeet)
T h�'
r�
i�7'��t Cily,s;ate,ZIP Code "
t%ice President of. Operations �
.
�e��ancr.z�numaer '�
� � (317) 817-6135 Fa°"'y°s�
p�:.;.. G
1 • • •
I lll
� 4=;nz�a�;,��prolessienal Icr i�e pro�ect lar wnlrn Ih�s'applica�ion,pians and specilicalions are beingJileO.I pereby certily:
I �.i, I am qualifietl and compe:zni to tlesign sucn builoings.structures..and systems and�have altached a copy ol my current registrelion card;
2. ihe O�ans and speciFicaoons filed in conjunaion wilr ihis appfication were�createtl byme antl r or�y my persons under my immediate perscnal
� s�perv�s�on acd will cemply with all zppiicaCle b�ilding laws�and rules ot the Commissioa�.
` 3. ina pro�ect aat=ccniainetl-on this zppiication arz correct arA torrespond wilh7he plans and specilicalions to 6e filed in conjunc(ion-with Ihis applicalion;
; ��. ihe oes�gn professional idemilied bzlew will inspect Ihe�cor,siruclion coverzd:�bythis appiicationat appropriatz imervals to deiermine general compliance
iwith ine releas=d cocumznlrano zpplicable roles ol Ihe Commission and wilfcause all neted tleviations Irom released documenls and code violations
i to Cz correueC or noeily Ihe owner and zuthonties having jurisdiciion oh,aii specitic deviations antl�code violacions;and
; 5. I zrum untler panairy ot pzrjurylhat ihe represzma�ions contained herein are true and I lurther understand thal providing lalse�information constilutes
� an act ol perjury.which is a Class D Feiory punishable�y a prison lerm and a linz.ol up�;o 510,000.
���z5ponsiE�liry is lor Ne following sys�ems:
, � Site � Foundzuon � StrucNral [v] ArchitecNrai ❑ Mechanical
� ❑ Plum�in
9 ; ❑ Eizctrical ❑ An Above ❑ Oiner (speclyJ
� � . . 5� ^aWre Name ol�rm(ilapp��cableJ
�;S'.
! �� ���_•'��� The SnterDesi n Grou Inc.
i , . Ndm�(f p2d pr pnnlPtlJ . AdDrPSS fnumDe!dnd 5tleE(f
' - , � - Blum 141 East Ohio Street
j'�SEAL) . _ i '� ' ,a regis::ai�on numoer
.. ��Ar[hi1EC( Cny,s�aie.ZIP code
- 2028 ❑ Eng�neer Indiana olis , IN 46204
� % ,�,•.�_ : ` NOTE SeaPand s�gnaw�e aniaetl Oelore reprWu<ncn�sr.au appear on eaU�page ol all O�aivings arA Telep�one number
� - . � �: Ine lilla page.of all speGlicalions.
� �'.���-� �: - .l J All correspondenre wdl Oe lo tleslgn.ArchilecUEngineer,ilnone I�en fo Ihe awner. ( 31 J� Z G3-9 GS J
:.�:.,�"�.,•�",:.j�n"ii9^;3'9f1PDessona�lryPedaa,nred� '— NOTARYCERTIFICATE
,Toel p. Blum STATE Of n�.�L�o.,..,`
:��o�a�a rfg,suaiion num�e� � ArChitect COUMY OF. �h } SS:
—g.c.�.�.
2p2g ❑. Er.gir,ezr Bzlore.me Ihe undzrvgned. a Noiary Publlc lor sald Counly antl Slate. personally appeared
ic2 J:.rn p13JOr�L3D�°� �1 p
�t a.z� P �c7.Yi,� ,who under lhe pznally ol perjury aCcnowledges Ihe
The InterDesign Group, Inc. i T , ,
. brey�i�ng s�atemems as irue te�s �Cay oi s /99 7
^C]rei>i��2DP•anC i:�22!1 � '
141 East qhio Screet s�gnaiureo�NOiaryP�bi�c . ,� �p ��{��
�CA� 56i1e ?IP�GCe � '�� /L -t-
Indianapolls I\T 46204 ti+r mmis� s����e=P�res. Comryolres�ae�ce -
' L�'u-.a.u-aii - 7.. � : r �i �7/13.t.�r ti
, - ,
=,,r z -
3. PROilEGT DATA
. - . .
ity
� _�(To be completed by submitter) Please,answe�all per6nenf.questions. SBC pio�ea nomber - F���n§'4aie
_ ' • � . . . • r .
�,copeolworfi� . _� -- - . . � . ' � . . - 7oialemis�ing(ilappGCablel - '
- � ❑ New buildin ❑ AOdition � qemoHelin ' - � � - - Sq�FI. �
. • Is ihis consuuctlon ihe resull ol Gre cr nawral disasier? Sawer ❑�Exisling❑PropoSed �otl�l�on p!app��catiie) Atlanlm�il apphcxo;el
❑ Yes � No Public ❑. Private ❑ None�� S . FI. $
Fire svppress:on sys�em in balltling - D=lailed suppression sys�em plans anG specs Remodeled(lla0fl��cab�rl Remodei�ng�l?aGa��cso�r�
Full ❑ Panial ❑ None � Provided ❑ Tofollow 18 825 S . FI. . � 56,475.
tl panlal,spzcily wnere' Locaied m Ilood piam(✓counry Toial bullaing area square leei Toeai pre�ea rov
p/an commissmnJ -
❑ ❑ No $
Bvildi�g�onstmclion type antl occupanq tlassif�ytion Build�r.g�eig�l �NUmper ol buiidings I�is submiltal Volvme cubk leei
(Sfonesl ' (DescnDe il necessaryl ' �Fee caiego,c omy: �
II - 1 Hour S rinkler
Indiana�reha0iiilalion slanCartl(Aule 8�useG? Evaioaiion Oocvmenls pwvidetl? Use ol wnverzion mle(l7ule 1,�proposetl?
❑ Yes No ❑Yes �NO ❑ Yes ❑ No
�oes pmjzn include:lCneck i7 YrsJ
❑ Elevator or lift ❑ Combustibie fibers slorage ❑ Fireworks storage - ❑ Explosives stcrage
❑ Hi R ile stora e ❑ Boiler or ressure vessei ❑ Hazardous or.flammable.malerials siora e
DescriDe.pmposed use ollaciiiry IN DETAIL,inUuding rypes o�Ilammable or com�usii�le maiedals storetl or�analetl' � �
0£f i ce._-._.Sns ur anc e. ........_
_._.. __..... _........ _
Describe previous or turreN use ol Iaalily IN GETAIL/I/esisling laulily/.'
.........Office_..-.....Iasuiaace. .........._. _. ._ ......... .____.... ......... .._............_ ............._ __......_...... �
Numbzr cl perscns xmplcyac -
(bfaz�snihi .
Generalcommenls' '
. Nom�er ol persons ipvai,n
� • . �
Has'mner wcrh at.mis I«aiion ever been Ned? - Coes pmject incWde usr ol a m3ster plan oesgn ielease or'a la<tory buiil moGWar or ao0de suuc;o:e'
Yes ❑ No ❑ Unknown ❑ Yas � No �
WOai year and monlh Previous SBC project number Nameal manulaclurer(d�ac�ory builq 61as�er plan!MoCular Iilt num0er or r,ooWar mcc,�a '
1/9 7 2 3 72 9 fi szal nvmber �
Has consWCtion started? I�Yes,has a notice ol violation or invesliga�ion Deen issuetl? II No,pmba�la construcilon stanfng tlale? '
❑ Yes No ❑ Yes . �,_,Na ASAP �
� � .
Ind�ana Uimaleizone Type ol heaeing'.luel Number ol ienanis � No.ol elecuic meiers No.ol gas�meiers BTU.'HFL5F Deq.F walls �
❑ North Q Cenlrai ❑ $puth � � (Adjus:edloropen�ngs �
Uo
Goes projea conlain skyligMS,greeNwuse,solanum,or it Yes,OTTV ol rool OTTV�oI wails RooPCailing assam�ly �
large glass area? ' UV I
❑ Yes No
� . Energy caiculalions pmvided? Potable�oi wa�er pro�bed7 is i�redre�iaiee? Au inlillreeon ra�e pe�7ao�e SC2.92 �Floors(Unne3:ro ea�c�� .
�❑ Yzs 0 No Q Yes ❑ No ❑ Yes Q No ❑ Yes ❑ No Uc
TmalNOn-resdenlial�IgNinq power Wtlgei T�ermova�rarge�eaung Tnermosiat range coolmg Siab at gratla '
KW R i
Generalmmmems' Crawi spaa wa��z '
R :
ACCESSIBIIRY' SEISMIC DESIGN
❑ Yes ❑ No Have accessible parkirg spaces and signage been pmvided? Islhis pmIea clissdied as an ESSENTIAL FaQliTV. �
❑ Yes ❑ No Does access w�ihin bullding,comply with TaDle 33-A I.B.C. ? GROUP E1 or HIGHRISE? � Yes L.� N�J �
(See lBC�Chapte�23J
❑ Yes ❑ No Oo Ioilel moms and equiDment meet accessibiliey code? Have seismic desiqn pwceaures �
❑ Yes ❑ No Does access to building meet accessibiliiy.code? been lollowed per code ❑ Yes ❑ No
❑ Yes ❑ No Is.buildin ;desi ned���lor access'adaolatiilit ? requirement?
rt ol la[iliiy(as li[en5etl0y Intljana�0epartmenf al HeaINJ�
11 nursing nom8 ,
❑ ResiOential cuslodial care Nursin home ❑ Out atienl sur e ❑ Hospital ❑ Intermetliale care -❑ Skdied care
'Atlmining antl discharge poliry prov�ae0 Plans sAov:uil�cal Oealilg area Emer e wer �
9 "n�° ❑ Generalor❑ Banery Nonz
❑ YBS ❑ No service .
❑ Yes ❑ No ❑ Oiher(Spxily�'
'NOTE:USE SEPARATE SHEET IFADOfT/ONAL SPACEIS REOUIRED paGE_
,
4. PROCESSING DATA � - � . .
� jFo�0lliw u5e Only) SBC p�ojecl number Fiing tla�e
. �
� � • � • �
• �
I . . . _ . ' ' . _ _.. . � . , . ._. TYPQ .
. .. _.. . .......__. _._.__...... . _.. ........... ......... _._ ..._........ ...... ......_ ... . . ........... OauOancy .
.. ...... . ._ ._. . _ _.._.. .. . ..... __. __ . . ..... _._. ..
I _ __ . FEE AMOUNT
. ..._......__._. . __..... ....... .. ._... ._... ._._. _...
:.
_..-_._... . .__......... _..._._.__ . ......_...._. .._ . _"........ .__.._. ......... .__.._...._ Filing
. ..__.... . ..__ . ... .___.. ... ___.___... _ . .. ...._.._. _ ___.. _
.............. .
............. Process �
Partial
. _ ... ..__.__.___.._____.._.._..._..._._..._..._.___._____'_.__.......___.._._...._:.__._. .
.................... Late
. ..___._ _._..._.. ....__...... .. ..._.._.. . . ......._. . _........ ___.__. . .
IFounda�ion
. . . ............_... ................. ___._... .. .� .......... . .. . ......._ .__ ......... ..._.____ _._..._..
I . . .. ........ . ... ._...... .. . ......... .____.._ . . _____...___- InspeCtion
......... ......_.... . _....... .......__......
.. ... __ ...__.. ..... .__.... ....... _...... . ._...___.. ............._ _..___ ....__ ......... Interim
, _ ...... __.__. .._.___....... ............. : ......._.._ -......_. ........._.. __ ......... ..._._.._.. _.___..
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I . .._...._ _............... ___. . ._._._ ... .. ... _ _ .
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lacal cn�c:ai atld�ess�NUmbe�and s;reefJ 1.D.number
� • •
i.
Gty.51ate-ZIP cctle
._..............____._......_.........._........._.._._.__..._......................._......,_.—._..._................._______—
i Generai.commenls
. . .... . _........_. ......_.._.. _._. .___.__ ..._......... ................ ... .__._ . ._._... ......... ....�.__ ._......_.. _...._'__
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.._ _ . . _. ._ ._ ....... . _ ..... .._._. ..._"_..
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CoCe:evlew oflicial .
...... _.__.___. . _ . ._._._... _....__.. _... ......__.... _._..........__ __ ___'"'
Ae�ease z:amp PARTIAL
RELEASE DATES
...... ___._. _.___.. _......... .._.. ._. ..__..._ _....._.._........___.
FounOaGon Structu�al
.........__._....__'__....._............_......._.........____...............................___..___.........._._......_"—"__
Medianical PlumDing
ElecUital Panitions Submined by ' ,
ArdiilxWrai Othe� Conslruction stan dale Actual o�cvpancy dale CerJlka�e o�Occupancy 6weE?
❑ Yes ❑ Na
51arMarC Release dale Issuing jurisQ�ction Oale�ssuetl
❑
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