ࡱ>  @ bjbjVV f0r<r<  8$< )2((^1)3)3)3)3)3)3)$*R6-xW) plp"ppW) l)p"  1)p1)n& 6 J=( +v' ()0)'h-Z-@=(   - =(PhJD<W)W) b"  HOMEOWNER AFFIDAVIT FOR HVAC PERMIT Address:___________________________________________________________________________________ Homeowner Name:_____________________________________________________________________________________ Day Phone:_______________________________________ Cell Phone:__________________________________________ By signing this application it is understood that I, ________________________________am the owner of the above mentioned property, am currently residing in the above mentioned property; if I am not currently residing in the property, I attest that I will reside there upon completion of the work. I also affirm that the home is not currently for sale, and that any and all HVAC related work being done in the above mentioned home is being completed by me and no one else. Only one (1) homeowner permit for construction of a new home shall be issued to an individual within a five (5) year period. I also understand that the work must meet the Kentucky Building Code and I am responsible for contacting the local EPA regarding reclaiming of Freon Certification. I am also required to obtain the inspection(s) from the OMPC to ensure the above requirements have been met. This includes a final inspection. If I am found to have falsified this application in any way, I will face legal action including a fine and/or imprisonment. Applicants Signature:_______________________________________ Date:___________________ Subscribed and sworn to before me on this the ____________day of ________________, 20_______ Notary Public:_______________________________ My Commission Expires:_______________________________ OMPCNew Form Word 97/2000/XP07/02 000  PAGE 2/ NUMPAGES \* MERGEFORMAT 1  OWENSBORO METROPOLITAN PLANNING COMMISSIONHVAC Permit Homeowner Affidavit 12/10 350a  PAGE 1/1 NUMPAGES \* MERGEFORMAT 1  270-687-8650 PLANNING Zoning Subdivision Addresses Street Access Points FAX 270-687-8664 270-687-8665 BUILDING & ELECTRICAL Plan Review Permits Inspections Serving Owensboro, Whitesville, and Daviess County, Kentucky  HYPERLINK "http://www.iompc.org" www.iompc.org  'U V z ~ 3 5 6 7 w } 0 : = D G d e MNO亴hO`@CJh:5: hL5hL hLCJjhLCJU\*hr|bCJ\mHnHu*jhLCJU\ hLCJ\<jhh0J@B*CJ$KHU^JaJ$hph*8hET?0J@B*CJ$KH^JaJ$hmHnHphu*0hh0J@B*CJ$KH^JaJ$hph9jhh0J@B*CJ$KHU^JaJ$hphhL5B*CJ$phhL@CJHhL@CJKIGWkd$$If4pF h'      af4$IfWkd$$If40F h'      af412hiv:||||||| ` v: $If]$If$If$If b#'dp$dN b#'dp &0278:<=>DEFGHIJdefgh¥qke[k[P[JC hL5\ hLCJhr|bCJmHnHujhLCJU hYCCJ hLCJ5hr|b0J@B*CJ$KH^JaJ$hmHnHphu0hh0J@B*CJ$KH^JaJ$hph9jhh0J@B*CJ$KHU^JaJ$hphhLB*CJ$phh=P@CJHhYC@CJHhL5CJ\ hYCCJhcsh,hhLjhLUijklmnv:v:v: v:$Ifgkd$$If0\ h' anopqrst `'/`'/`'.`'/`'^~`'^`'/v`'^t$ X a$  X "gdO` &dPgkd$$Ifp\ h' a  _`Խ hET?CJhr|bhL0J6]j<hL6U]jhL6U] hL6] hL5 hLCJhO` hO`5\hL`'v:$hv]h^va$gdET? H 00&PP/R :pYC/ =!8"8#$0%0 @`'nc\ҶvX-PNG  IHDRle^@2gAMAPLTEٟ pHYsr5rf1IDATxAr( @qy>H}4XXH1+=Օ$y PXSp~|9p=Vߕ\+c=`mzBj##{hPΟZܞJ?7jʬ9a@J|WZ|DWj65|IZQc[V<`#uE*qZ|w;zw7;Mh Z66hmiBFv bp!*p# w\]*\?/Cvwۢ3g|,=ׄm3T#=ǧ">?'s aewঀ/)/Mxi|^< +^Zڀ?Є7 \ /mքv>'sJˢ܄o PCC=珞'Nwx;/c^{̫-sU?jg߀5&| mim?Uт۱ayw?8S).^, 'U΁`D5)߈.JwGoe~-@ |} A4L0u +!71x ;<'] qa,!/+* ΄[uzm-)ElX YcfDp֨\*: #b P=8x%eu=-6U`0G+1'?)yQCQI6jaC\ q.}.S?͕O3qFL~KL[krk AxK4\tVwB5!\I *rŒ/R;iB}#\1{ܩfiy\hrkX0pDž8$p-%;Z#3׆_{zMG@BV Title$<@&a$5CJ KHOJQJ\^JaJ jORj Form Number$ d1$a$ @B*CJTKH,OJQJhphOb Form Title/$ d&#$+D1$a$'@B*CJ$KH(OJQJ\^JhphfOrf OMPC Footer$ X da$ B*CJ_HhmH phsH tH ZOZ Note Textd%6B*CJOJQJ_HhmH sH tH ^O^ Table 9pt H]H(B*CJOJQJ_HhmH phsH tH XOX Spacer 4ptdP"B*CJOJQJ_HhmH sH tH fOf Table TextHd]H(B*CJOJQJ_HhmH phsH tH fOf Spacer 8ptd h"B*CJOJQJ_HhmH sH tH lOl OMPC page 2 Zd^#5@B*CJ$OJQJ\^Jph:O: Arial 9CJOJQJ^J6U@6 Hyperlink >*B*phbOb Table 9pt Bullet# & F == ^=` \fOf Table Text Bullet)! & F == d^=` j@#j YC Table Grid7:V"0" *%&'TUVWHbcdefMNO12hijklmnopqrst 000000000000000000000000000000`@0@0 @0@0 @0@0 @0 @0 @0 @0 @0 @0My0@0My0P@0 @0@0@0@0 d{0 @0@0 @0@0 @0 @0 @0 @0 @0 @0 @0@0My0 P@0@0@0@0@0@0My0OEM90M90M90M90M90M90M90M90M90M90M9006\\^ in  *135PR !!X  /Xb$eD4Hݝ=(b$c\ҶvX-J*@ (  J  # A" 0( 66WWWxxx B S  ?^4dJDeJ,"fJ"gJ<"hJ#iJ#jJ=IFD="2  FOR HVAC PERMIT=NHHEFHCCHS= 2 < 8 2   8 2   8@"Arial-2 i[Address:___________________________________________________________________________________7...**/../../../..//.../../.././../../..//.../../.././../../..//.../../.././../../..//... 2 i .@"Arial- 2  $ 2  $-2 [dHomeowner Name:_____________________________________________________________________________________6*?**5**6*>**)**)***)****)**)***)**)***)**)*)****)**)***)**)***)**)*)****)**)***)**)***)**)*)**** 2 [# '- 2  $ 2  $-)2 KDay Phone:__________6*%2****)***)**)**2 KS_____________________________ Cell Phone:__________________________________________*)**)****)**)***)**)***)**)**6*2*)*****)**)***)**))****)**)***)**)***)**)*)*** 2 K ' 2  ( 2  (- 2 T -2 \By signing this application it is understood that I, ________________________________am the 8(0*./..0.*0/..*./.00*0/...*/..0/.00.../../../.././../../.../../../..G0..g2 =owner of the above mentioned property, am currently residing /;....../.*.G../..../..(.G*...'.*...2  in .D2 & &the above mentioned property; if I am .././).G..........(-F[2 t5not currently residing in the property, I attest that ..*...(.*/..../....(/.*/.M2 t , I will reside there upon completion of the <.*...../...*.G.......2 twork<.+2 t . I also .*-52 affirm that the home is not .F......G.*..2  currently *...(q2 D for sale, and that any and all HVAC related work being done in the .*../../../(....=77</...<.+...../.../.n2 4 Babove mentioned home is being completed by me and no one else. On../).G..../...G.*....*.G..../(G..........*/A.2 4 [ ly( 2 4   2 4 o..2 4 ne (1) homeowner permit/....G..;....G 2 4  G2 (for construction of a new home shall be .!*..*.*..!.!/!./<"..G.!*..".."2 issued**../a2 9 to an individual within a five (5) year period. I also i!."/.!/.*./."<./!.!).!/"(.."...."!".*.F2 'understand that the work must meet the ....*/...../;.+G-*G....2 Kentucky7/..*,'X2  3 Building Code and I am responsible for contacting 8....=.././..G.)...*./.*...*../2 S the local EPA regarding ..8.*.98778/.././82 S  reclaiming.*.G..)2 S J of Freon Certificat8.83...9</*.F2 S [ 'ion. I am also required to obtain the ./888.G8.*.8/../.8.9.../8./L2 +inspection(s) from the OMPC to ensure the a .*..*..*.G..AE7<./.*.../.2 [ bove/.*.Y2  4 requirements have been met. This includes a final /...G..*./)/././G.4.*.*./.*/..2  einspection. If I am found to have falsified this application in any way, I will face legal action in.*..*...G...././)..*/./*./.*....//(<0(<.*./...*/..2  (cludingy*/...2  0 a / 2   .2 s fine a...(2 s nd/or imprisonment.t/..G.*..G.. 2 s u - 2  - 2 2  - 2  - 2  -2 R WApplicants Signature:_______________________________________ Date:___________________7./*/.*7...../../.../../.././../../..//.../../.././.</././.../../.././../. 2 R d .- 2  $ 2  $-2 K\Subscribed and sworn to before me on this the ____________day of ________________, 20_______7..**/../..+<.../...G....*/../../.../../.0(../../..//.../../././../.. 2 Kv .- 2  $ 2  $-O2 D -Notary Public:_______________________________o<..(8..*././../../.../../.././../../... 2 D .- 2  $ 2  $-[2 =c5My Commission Expires:_______________________________ F(=.FG)*..7*/.*//.../../.././../../..//.../... 2 = .-                     ՜.+,D՜.+,X px  formsompc  OMPC Form xxxx Title 8@ _PID_HLINKSAdD http://www.iompc.org/  "#$%&'()*+,-./012345679:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry Fm+Data 1Table!-WordDocumentf0SummaryInformation(87DocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q