HomeMy WebLinkAboutBLD-2018-0527 - DECONSTRUCTION & DEMOLITION (2) MAY 31 2018
CITY ? ' ?r
PLANNING, COMMUNITY, & ECONOMIC DEVELOPMENT DEPARTMENT
i oW DEMOLITION & OIL TANK DECOMMISSIONING PERMIT APPLICATION
t, y Mailing Address: P. O. Box 547, Anacortes, WA 98221
` 9 x Office Location: 904 6`h Street, Anacortes WA 98821
Phone: (360) 2934901, Fax: (360) 293-1938
PLEASE REFER TO THE PERMIT CHECKLIST THAT FOLLOWS FOR SUBMITTAL REQUIREMENTS
BUILDING DEMOLITION: g( N/A ❑ COMPLETE BUILDING DEMOLITION
❑ PARTIAL DEMOLITION ❑ RESIDENTIAL ❑ COMMERCIAL
❑ FLOOR AREA TO BE DEMOLISHED: ❑ METHOD OF DISPOSAL:
❑ DATE OF CONSTRUCTION OF STRUCTURE TO BE DEMOLISHED
UNDERGROUND OIL TANK DECOMMISSIONING: X N/A ❑ REMOVAL
❑ ABANDONMENT IN PLACE (FIRE DEPT, APPROVAL RQD) ❑ SIZE OF TANK:
❑ APPROXIMATE AGE OF TANK: ❑ DISPOSAL LOCATION:
❑ DATE OF PUMP & RINSE: ❑ ICC CERT #:
❑ IF ABANDONED, SPECIFY TYPE OF INERT FILL:
PROJECT ADDRESS ( treet, Suite #): PARCEL( ):
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APPLICANT: Phone:
renla� rrLI LkrJ✓ LL � 368M3020
Address (Street, City, State, Zip): &Mail Address:
3022 v tp�s LAM r t2Z21 L t Ma . , c A01
PROPERTY OWNER: Phone: ll f t
Address (Street, City, State, Zip): E-Mail Address:
3017. eke. Ao 22_ 1
Address (Street, City, State, Zip), E-Mail Address:
CONTRACTOR / DECOMMISSIONER'S FIRM NAME: Phone:
Address (Street, City, State, Zip): &Mail Address:
c " ./ I 21
*All Contractors & subcontractors must have a valid City ofAnacones Contractor' s License #: Ex
It Date:
CUL6 MG 62 N
business license prior to doing work in the City. Contact the City s Business License #i E . Date:
Finance Department at (360) 2994968. nt;l 116 30 ' f o , c
PROPOSED WORK: q clet
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I declare under penalty of perjury that the information I have provided on this form/application is true, correct, and
complete, and that I am the property owner or duly authorized agent of the property owner to submit a permit
application to the City of Anacortes.
Print Name: Sksi 41AT tr1f' _ Owner ❑ Other X (specify): 45
Signature: S, A, Date: 2l�
Page I of 2
MAY
3 1 2010
PLANNING, COMMUNITY, & ECONOMIC DEVELOPMENT DEPARTMENT
% Y °� DEMOLITION A OIL TANK DECOMMISSIONING PERMIT CHE If i
17 y Mailing Address: P. O. Box 547, Anacortes, WA 98221
° w Office Location: 904 6" Street, Anacortes WA 98821
Phone: (360) 293-1901, Fax: (360) 293-1938
UTILITY DISCONNECTION: i$( N/A
WATER DEPARTMENT: ❑ YES ❑ NO ELECTRICITY: ❑ YES ❑ NO
GAS: ❑ YES ❑ NO CABLE TV: ❑ YES ❑ NO
PERMIT TYPE :
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SUBMITTAL REQUIREMENTS: C C c
(The number indicates the number of copies for o S
submittal -if applicable). o a
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Demolition Permit & Oil Tank Decommissioning Application 1 1 I
Site Plan 1 1 1
Pedestrian Safety Plan (for Demolition Permits) 1
Asbestos Survey —Prepared by a Washington State Certified Asbestos 1 1
Abatement Contractor (for Demolition Permit)
Provide Proof of NWCAA Demolition Permit Approval '
City of Anacortes Fire Department Tank Removal Permit'
If the building is 50 or more years old, provide evidence at e V/
Department of Archaeology and Historic Preservation (DAHP) has
determined the building to be insignificant/significant. If the building is
determined to be significant, SEPA environmental review may be required.
NOTE:
t . Please contact the Northwest Clean Air Agency (NWCAA) located in Mount Vernon, Washington at
(360) 428= 1617 or online at http://nwcleanairwa.gov. Unless deemed exempt by the NWCAA, all city
required demolition permits also require a demolition permit from the NWCAA. You can also contact
the NWCAA for a list of WA State Certified Asbestos Abatement Contractors if needed.
2. Oil Tank Decommission Permits also require a "Tank Removal Permit" from the City of Anacortes
Fire Department. Please contact the Fire Department at (360) 293- 1925 to obtain a permit application.
Page 2 of 2
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