FORM: DEMO-1
CITY
OF LACEY
Community and Economic Development Department
420 College Street SE
Lacey, WA 98503
(360) 491-5642
CASH OR CHECK ONLY PLEASE
DEMOLITION PERMIT APPLICATION
Type of Permit (check one): ( ) Residential ( ) Commercial
Project Address __________________________________________________ Parcel Number ______________________________
L
ot Number ______________________ Subdivision ________________________________________________________________
B
uilding Area (Sq. Ft.) ________________________ No. of Floors _________________ Number of Buildings _________________
Owner ______________________________________________________________ Phone Number ________________________
A
ddress ______________________________________ City ______________ State _________ Zip Code ___________________
Contact Person _____________________________________________________ Phone Number ________________________
C
ell Phone __________________________ Fax Number ______________________ E-mail _______________________________
A
ddress ______________________________________ City ______________ State _________ Zip Code ___________________
Scope of Work __________________________________________________________________________________________
_
_________________________________________________________________________________________
_
_________________________________________________________________________________________
__________________________________________________________________________________________
(Please include an area map and a detailed site clean-up plan with application, ALONG WITH YOUR
APPROVED OLYMPIC REGION CLEAN AIR AGENCY [ORCAA] DEMOLITION PERMIT.)
Contractor _________________________________________________ Phone _________________ Fax ________________
Address ____________________________ City _______________ State ______ Zip _________ E-mail ___________________
Contractor’s License Number ____________________________ Expiration _________ City Bus. Reg. ______________________
I
hereby certify that the above information is correct and that the construction on, and the occupancy and the use of the above-
described property will be in accordance with the laws, rules and regulations of the State of Washington.
_
_______________________________________________________ ________________________________________
Applicant’s Signature Date
_
_______________________________________________________
Print Applicant’s Name
click to sign
signature
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