19-17 Scrap Metal License Approval

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i i Ir LCf}ErAR f OF STATE ZONING AFFIDAVIT t. t. SERVICES DIVISION ^ " r , State Form 55936(11-1S) ',i.est,,,iashington Street Rion E-018. nd arrapolis,IN 46204 0 w✓ )eearerrSl sos.ia.gov (3171233-1915 INSTRUCTIONS: 1.Complete in blue or black ink or print completed affidavit I 2.Section 1 must be completed by the applicant. 3.Section 2 must be completed by the zoning official with jure dlcti_n over the-dasci,ned real property. if no person or officer has Jurisdiction,the applicant must submit a written statement by the executive of the ttr,,!in which the real property is located indicating that the proposed location is zoned for the operation of the business'c n:ch the applicant.leaks a iicerss. 4. The completed affidavit must be mailed,faxed,or emailed to the Indiana Secre'a y or State Auto.r.Oeaier Services Division Your license application cannot be processed until a completed affidavit or wntlen statement is received. SECTION 1-•TO BE COMP' TED B"APPLICAAT Name in which the Dealer license will be issued Doing Business As‘DBA)name) Lege:ra..e o,Vie b.si aml -s. ../.,arr,e j go j 1, - Btre dress(Proposed ass tocaNat umber and street) City State ZIP Code { County C)0 S . ' ' +jam( {/' _ -r` ;-,{ , J--,r�, i. A License Type 0 Automobile Auction 0 Converter Manufacturer 0 Mar;u!acttirer ❑ omotive Mobility 0 New or Used Dealer fl Trarsier l.N Automotive Salvage Recycler 0 Distributor ❑ 'stiatercraf, 1 Type of Activities to take place at the location - -- — —� (Check all that apply.) } © Selling new and used vehicles ❑ Selling motor vehicles to ceaiers o ori d tiro as a;.st mule.* Selling used vehicles 0 Belting MotorcycieslMotor Driven Cycles �b•re', ng o {sr-a iii a v h:ciea sca+ het.r- lar•Om;:vnenl par's s ❑ Settling Watercrafttwatercratt Trailers ice. Rabuil..in al,:age. a. ,< ._ 1 ❑ Selling Trailers u Dispo try re c .off^ate'acility Selling ATV1UTViSnawntobiles 0 LI Addto, ti _ o fro r -c s , or vehicle Selling RVs 0 Providing a facii-z., .r,he curctese an_s i c on the bass of bids(Auction) to.more❑ Manufacturing c:assrnta ;new n-c- a o-oo^err,parts a ❑Ei Sung Manufactured Homes r, p etting used major component parts of vehicles �O ss -cc a b erg;strat or: ran thirty f30!lay ❑ Belting adapted vehicles E'c= y;i.. °" 'S -n _..•:ay _ ecycGng o`-chides.vehicle hulks or the ❑ Title TransferfFinanraa!lnstiiutionlinsurance Pans of vsh:-.; Company Zoning(Select one of the following.) - — -- I 1 # ❑There is a person or official charged with enforcing zoning ordinances for the above deschtec crorer;. imus:corno!Cte Section 2). I 0 There is no person or official charged with enforcing zoning ordinances for the above deserted property ,-r isr su omit a written statement as described I in instruction#3 above). st I hereby certify.under the penalty of perjury,that I am authorized to make this application and Inat rhe answers and Information contained in this application are true and correct. Signature _ Date Signed(mm/ddiSignature of Appti•s<� � 'ti'rin- r ,,0',..0 cant diri cfi"'1"iic ler — --- "' • • SECTION 2-TO BE COMPLETED BY ZONING OFFICIAL • li I,the undersigned,swear or affirm without stipulation that the above described property complies with iocai zoning ordinances or other local ordinances for the type of business indicated above. i understand that making a false statement may constitute the crime of perjury. Signature of Zoning Official Dere'r '-_-.'::-..,/,-,,;, i Printed Name of Zoning Official t . Ayoka Paek -'.itii,s`& Bcsirtoss Services Administrator! Authorizing — Agency — — — — — -- St.Joseph County/South Bend Building Department _A___— 1 it I i i 9 1