Office of Building Services Page 1 of 2 BF12 Demolition Application & Affidavit
Revised September 29, 2017
Affidavit of Requirements for Demolition of
Structures
I, , the applicant for a Lake County Permit, hereby certify that
the proposed structure for demolition is_______ three stories, or less, or _______ the structure is above
three stories.
(Please check appropriate line.)
Legal description of property where demolition is proposed:
Lot/Parcel: Block: Subdivision:
Section: Township: Range: Alt. Key:
I certify that I have provided to the Lake County Office of Building Services the following list of items:
1. Building permit application form.
2. Demolition/Owner’s affidavit (signed and notarized).
3. Proof of ownership for property to be demolished. (tax receipt, property record card or warranty deed)
All owner’s listed on a property must sign an Owner’s Affidavit.
4. A plot plan of the property showing all structures, septic tank, and well, with proper identification
showing structure to be demolished.
I certify that I have notified all utility companies (power, gas, and telephone) of my intentions to demolish the
above described structure.
I certify that all debris from the above described property will be taken to the appropriate Solid Waste drop off
site within Lake County and disposed of properly. The receipts from the Solid Waste drop off site will be
posted at the job site for final inspection.
I certify that if it is determined that asbestos is found in the structure, the Lake County Building Services
Division will be notified, and all requirements concerning asbestos abatement outlined in Chapter 469,
Florida Statutes, will be strictly followed.
I understand that two inspections are required. One inspection before demolition begins for verification that
all utilities have been disconnected in an appropriate manner, and a final inspection after the structure is
demolished and all debris removed from site.
Signature of person responsible for demolition
License # _______________________
Printed name of person responsible for demolition (If applicable)
STATE OF FLORIDA
COUNTY OF LAKE
The foregoing instrument was acknowledged before me this ______ day of __________________, 20______,
by , who is personally known to me or who has produced
as identification and who did ____ or did not ____ take an oath.
Notary Public (Signature) (SEAL)
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