January 2019
CITY OF STAYTON
APPLICATION
TO DEMOLISH A BUILDING
PROPERTY OWNER:
Mailing Address:
City/State/Zip:
Phone: ( ) - Email:_____________________________________________
APPLICANT:
Mailing Address:
City/State/Zip:
Phone: ( ) - Email:_____________________________________________
LOCATION:
Street Address: ______________________________________________________________________
Assessor's Tax Map: 091W _____________________ Tax Lot Number: ____________________
Closest Intersecting Streets: ___________________________________________________________
Type of Structure to be demolished: residential commercial industrial accessory structure
The structure is connected to the following utilities: city sewer city water city storm water collection
electricity natural gas
The Oregon DEQ requires an asbestos survey to be performed by an accredited inspector to determine the
presence of asbestos-containing materials in or on all structures prior to demolition activities.
I intend to remove a structure on the above designated property. Removal of the building will be accomplished
by:
DEMOLITION BURN BY STAYTON FIRE DISTRICT
If the building is connected to city sewer, water or storm water collection service, I will notify the Stayton Public Works
Department at least 48 hours before demolition is scheduled to begin and demolition will not commence until I have
been notified that utilities have been disconnected. I understand it is my responsibility to coordinate with the private
utilities.
• Water: The City will remove the meter and disconnect the service.
• Sewer: The owner is responsible for requesting a locate through the Oregon Utility Notification Center.
The Public Works Department will locate the sewer lateral within the Public Right-of-Way and identify
where the sewer line must be disconnected. The applicant is responsible for disconnecting and capping
the line. Once line has been capped, the applicant must call the Public Works Department for an
inspection.
SIGNATURE OF APPLICANT: DATE: ________________________
DO NOT WRITE BELOW THIS LINE (OFFICE USE ONLY)
Application received by: ____________________________________ Date: _________________
Sewer: Locate date: ________________ Water: Meter #: _________________ Reading: _____________
Capped date: _______________ Date Removed: ___________
Initials: ____________________ Initials: _________________
Notify customer upon completion Notify Fire Department Scan to database
Copy to GIS/Planning Reading to City Hall (UB)
click to sign
signature
click to edit
![]()
