Free 00786.PDF - Indiana

NOTICE OF ASSESSMENT REGISTRATION
State Form 786 (R2 / 6-87)

Number County

Date

INSTRUCTIONS: An owner of real property, or the owner's agent, is required to file this notice with the County Assessor before demolishing, structurally modifying, or improving the property, unless the demolition, structural modification, or improvement: (1) requires a permit from the state or a political subdivision or (2) costs $500 or less for materials or labor, or both. Any owner who fails to file this notice when required is subject to a civil penalty of $100 (see IC 6-1.1-5-15) AMONG THE ITEMS SUBJECT TO THIS NOTICE ARE: l l l l Construction or placement of building, swimming pool, or other yard structure. Horizontal or vertical extension of building, including extensions such as patios. Major remodeling, including finishing of attic or basement. Addition (not replacement) of fireplace, central air conditioning, central heating, commercial paving, bath tub, sink, toilet, water heater. BASIC INFORMATION
Name of registrant Telephone number

Address of registrant (number and street, city, state, ZIP code) Telephone number

Name of landowner

Address of landowner (number and street, city, state, ZIP code)

LOCATION OF REAL PROPERTY
Section Township Range Lot Block Subdivision or addition Parcel number

County road or street

City

DESCRIPTION OF DEMOLITION, STRUCTURAL MODIFICATION, OR IMPROVEMENT

ESTIMATED COST INFORMATION IS CONFIDENTIAL PER IC 6-1.1-35-9 ESTIMATE
Cost of materials and labor Commencement date Completion date

Signature of registrant

Date signed