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PLANNING,COMMUNITY, &ECONOMIC DEVELOPMENT DEPARTMENT <br /> DEMOLITION & OIL TANK DECOMMISSIONING PERMIT APPLICATION <br /> Mailing Address:P.O. Box 547,Anacortes, WA 98221 <br /> 74, <br /> Office Location: 904 6th Street,Anacortes WA 98821 <br /> Phone: (360)293-1901, Fax: (360)293-1938 <br /> PLEASE REFER TO THE PERMIT CHECKLIST THAT FOLLOWS FOR SUBMITTAL REQUIREMENTS <br /> BUILDING DEMOLITION: 0 N/A El COMPLETE BUILDING DEMOLITION <br /> O PARTIAL DEMOLITION RESIDENTIAL 0 COMMERCIAL <br /> ID FLOOR AREA TO BE DEMOLISHED: 0 METHOD OF DISPOSAL: <br /> O DATE OF CONSTRUCTION OF STRUCTURE TO BE DEMOLISHED <br /> UNDERGROUND OIL TANK DECOMMISSIONING: 0 N/A 0 REMOVAL <br /> 1ABANDONMENT IN PLACE(FIRE DEPT.APPROVAL RQD) JR"SIZE OF TANK: 3 C <br /> D APPROXIMATE AGE OF TANK:3 D vial 0 DISPOSAL LOCATON: 'S4A, RL <br /> O DATE OF PUMP&RINSE: 0 ICC CERT g: 1 <br /> 0 IF ABANDONED, SPECIFY TYPE OF INERT FILL: <br /> PROJECT ADDRESS (Street Suite j*, PARCEL(S): <br /> f3iAPPLICANT: Phone: <br /> e:-JV &):8''- -S S-577 <br /> Address(Street,City,St ,Zip): E-Mail Address: <br /> ? ;2 /to . 'Mei Co-se.A-ik yvi- yeAk-NO-C.ev.,- <br /> PROPERTY. i OWNER: . Phone: <br /> Address(Street,City,States Zip) E-Mail Address: <br /> /9/ 1. <br /> Address(Street,city,State,Zip E-Mail Address: <br /> a-4A 9 &,.2a <br /> CONTRACTOR DECONEMISSIONER'S FIRM NAME: Phone: <br /> ,1),21 I <br /> Address(Street,City,State Zip): E-Mail Address: <br /> i77 4 A)/ ( itAj Sit,Sec4,41<i• 6;? <br /> Contractor's License 4: 6,1 Exp.Date: <br /> *All Contractors&subcontractors must have a valid CIO of Anacortes T s.,(6 e4.2 <br /> business license prior to doing work in the City. Contact the City's Business License#: Exp.Date: <br /> Finance Department at(360)299-1968. <br /> PROPOSED WORK:' - t--- -AL i.,A1 <br /> (IL-fel 1-:112-e-c4rer% <br /> (.J v/ &&JL •.€ v <br /> I declare under penalty of perjury that the information I have provided on this form/application is true,correct, and <br /> complete,and that I am the property owner or duly authorized agent of the property owner to submit a permit <br /> application to the city of Anacortes. <br /> Print Name: V Owner 0 Otper-tr(specify): <br /> Signatur7/4 Date: 7/ I 1fdz) <br /> Page 1 of 2 <br />