Revised 11-30-2011
$50.00 Application Fee $50.00 Permit Fee
Name: Name: Company:
Address: Address: Contact:
City: City: Address:
State: State: City: Zip Code:
Zip Code: Zip Code: Day Phone:
Day Phone: Day Phone: Cell Phone:
Cell Phone: Cell Phone: Fax:
Fax: Fax:
Registration No:
Expiration Date:
Designated agent/contact for application (check one only):
licant Owner Contractor
Site Address: Lot/Block#: Parcel I.D. #
Plat Name/Short Plat #: Lot Size: acres sq. ft.
Do you own adjoining pieces of land? Yes No Construction Type:
Is the property within 200 feet of a shoreline? Yes No Residential Unit Type:
Project Start Date: Last Use:
Project End Date: Floor Area: sq. ft.
Asbestos on site? Yes No Utility cut off date:
Lead paint on site? Yes No
Waste Disposal Facility receiving waste from this project: Can this facility handle hazardous materials? Yes No
If no, please provide the name of facility receiving hazardous
materials from this project.
Name: Name:
Mailing Address: Mailing Address:
City: State: Zip City: State: Zip
Phone: Fax: Phone: Fax:
Revised 11-30-2011
(Check the boxes provided indicating attachments included with this application)
Demolition plan and schedule
Site Plan. Complete site plan showing site safety and all utilities serving the structure to be demolished. These utilities include:
water supply, sewage disposal, electrical service, and gas supply (natural or propane). All utilities MUST BE PROPERLY
ABANDONED OR CAPPED. Please provide utility cut off date and a description on how each utility was abandoned.
Burn Permit and/or Fire Marshal Approval. If your intent is to burn the structure, you must include with this permit
application a Tribal Burn Permit and approval notice from local fire district.
ASBESTOS: It shall be presumed that all building on the Swinomish Indian Reservation have “friable asbestos.” Therefore, prior to
issuance of a Tribal Demolition Permit, the Swinomish Indian Tribal Community will require testing to be done pursuant to the
Northwest Air Pollution Authority (360-428-1617) and the results attached to the demolition permit application form.
Proof of Approval for Disposal and a Waste Shipment Record.
Waste Shipment Record
LEAD PAINT: It shall be presumed that all buildings on the Swinomish Indian Reservation built before 1990 have lead paint.
Therefore, prior to the issuance of a Tribal Demolition Permit, the Swinomish Indian Tribal Community will require testing to be done
on all suspect paint.
Lead Paint Testing performed
It is the responsibility of the permit holder to notify the Swinomish Office of Planning and Community Development and ensure that
the required inspections are made. Swinomish Demolition Permits expire three (3) years from date of issuance. The Swinomish
Indian Tribal Community may, in writing suspend or revoke a Demolition Permit whenever the permit is issued in error, or on the
basis on incorrect information supplied by the applicant, or when it is determined that demolition work is in violation of Tribal and
federal laws. The duty to ensure conformance rests with the permit holder and their authorized agent(s), not the Swinomish Indian
Tribal Community.
Application is hereby made for a permit to authorize activities described herein. I certify that I am familiar with the information
contained in this application and that to the best of my knowledge and belief such information is true, complete, and accurate. I
further certify that I possess the authority to undertake the proposed activities. I hereby grant to the officials of the Swinomish
Indian Tribal Community the right to enter the above-described location to inspect the proposed and/or completed work.
Signature (Required): ___________________________________ Date: _________________
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