Applicant Property Owner:

Address:___________________________ Address:_______________________________

"""" _______________________________ """"" _______________________________

Phone:_____________________________ Phone:_________________________________

Responsible Party: (General Contractor or Agent of Owner)

Name:______________________________________

Address:____________________________________

___________________________________________

Phone:______________________________________

Contractor License #___________________________

Statement of Utilities:

Please provide a brief description of how each of the utilities will be disconnected,

Removed and/or capped.

Electric:__________________________________________________________________

Water:____________________________________________________________________

Propane:__________________________________________________________________

Septic:____________________________________________________________________

Dates of Removal:

Commencement Date:________________________________

Completion Date: ___________________________________

Removal Methods:

Provide a brief description as to how the building will be removed including

methods for removal and equipment to be used.___________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Hazardous Material:

Does the building contain any hazardous materials?_______________________________

What is the plan for the removal of these materials?_______________________________

__________________________________________________________________________

__________________________________________________________________________

Placement of Debris:

Where will the debris be taken?_______________________________________________

__________________________________________________________________________

__________________________________________________________________________

Where will hazardous materials be taken?________________________________________

__________________________________________________________________________

Site Plan:

Please attach a site plan showing the property lines, the building(s) to be removed

and those that will remain, location of all utilities and point of disconnection. The

plan need not be drawn to scale but must include dimensions of lot lines and

distances from the buildings to be removed to the lot lines.

Hazards:

Are there any problems or hazards that might occur as the result of the removal of

this or these buildings?_______________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Lakefront Lots:

Have you obtained a soil erosion permit from Presque Isle County for this

activity?_______________________________________________________

Statement of Authorization:

I (we) the owners of the before mentioned property, authorize the Responsible

Party listed on this application, to remove the building or buildings as indicated in

this application and as shown on the site plan.

________________________________ __________________________________

Date:____________________________ Date:_______________________________

Approval: Permit #:__________________________

Conditions:_______________________________________________________________

_________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Signature:_______________________________________

Date:____________________________________________

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