Fillable DEMOLITION PERMIT APPLICATION

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DEMOLITION PERMIT APPLICATION

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MASON COUNTY
PERMIT NO.______________________
COMMUNITY SERVICES DEPARTMENT
BUILDING • PLANNING • FIRE MARSHAL
WWW.CO.MASON.WA.US (360) 427-9670 Shelton ext.352
Mason County Bldg. #8, 615 W. Alder St (360) 275-4467 Belfair ext. 352
Shelton, WA 98584 (360) 482-5269 Elma ext. 352
DEMOLITION PERMIT APPLICATION
OWNER INFORMATION:
NAME:_______________________________________
MAILING ADDRESS:__________________________
CITY:______________ STATE:_______ ZIP:________
PHONE:_______________ CELL:_________________
EMAIL:_______________________________________
PARCEL INFORMATION:
PARCEL NUMBER (12 DIGIT NUMBER) ______________________________________ FIRE DISTRICT _______
LEGAL DESCRIPTION (ABBREVIATED) ___________________________________________________________
SITE ADDRESS ____________________________________________________ CITY ________________________
DIRECTIONS TO SITE ADDRESS:
IS PROPERTY WITHIN 200 FT:
SALTWATER⎕ LAKE⎕ RIVER/CREEK⎕ POND⎕ WETLAND⎕ SEASONAL RUNOFF⎕ STREAM ⎕
DOES PROPERTY HAVE SLOPE(S) WITHIN 300 FT OF THE PROJECT- GREATER THAN 14% YES⎕ NO ⎕
IF YOUR PROJECT IS LOCATED ADJACENT TO OR WITHIN AN AREA THAT IS LISTED ABOVE, PLEASE
CONTACT THE PLANNING DIVISION OF COMMUNITY DEVELOPMENT PRIOR TO DEMOLITION TO
ENSURE REDEVELOPMENT.
USE OF STRUCTURE BEING DEMOLISHED (RESIDENCE, GARAGE ETC.)____________________________________________
HOW WILL THE DEBRIS BE DISPOSED OF?:
__________________________________________________________________________________________________________
OWNER / CONTRACTOR acknowledges submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below. I declare that I am the owner, owners legal representative, or contractor. I further
declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the necessary
parties, including any easement holder or parties of interest regarding this project. The owner or authorized agent represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structure(s) for
review and inspection. This permit/application becomes null & void if work or authorized construction is not commenced within 180
days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF
INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
X__________________________________________
Signature of Applicant
X__________________________________________
_______________________________
Date
__OWNER /__ REPRESENTATIVE /__ CONTRACTOR
Print Name
PROVIDE A PLOT PLAN INDICATING LOCATION OF STRUCTURE TO BE DEMOLISHED
CONTRACTOR INFORMATION:
NAME:_________________________________________
MAILING ADDRESS:_____________________________
CITY:____________ STATE:_________ ZIP:_________
PHONE:________________ CELL: _________________
EMAIL :________________________________________
L&I REG #_____________________ EXP. ___/___/___
DEPARTMENTAL REVIEW
APPROVED
DATE
DENIED
DATE
BUILDING DEPARTMENT
PLANNING DEPARTMENT
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Olympic Region Clean Air Agency
2940 Limited Lane NW
Olympia, WA 98502
(360) 539-7610 • FAX (360) 491-6308
South Bend Office (360) 942-2137
Port Townsend Office (360) 338-6419
www.ORCAA.org
Demolition Permit
Demolition and renovation projects within Clallam, Grays Harbor, Jefferson, Mason, Pacific, and Thurston
counties REQUIRE A PERMIT and require that the following conditions be met prior to the demolition.
Olympic Region Clean Air Agency (ORCAA) regulations define a demolition project as the wrecking, razing,
leveling, dismantling, or burning (by a fire department for training purposes) of a structure, making the structure
permanently uninhabitable or unusable. Renovations include the removing of load bearing structural members,
but not to the extent to make the structure uninhabitable.
The following information is merely a reference guide and not a substitute for agency regulations.
1. A good faith asbestos survey is required for any demolition. The survey must be conducted by a certified Asbestos
Hazardous Emergency Response Act (AHERA) building inspector. Qualified contractors and inspectors may be
found in your local Yellow Pages, through the Washington State Department of Labor and Industries, or on
ORCAA’s website.
2. Asbestos samples must be sent to a NVLAP Laboratory (National Voluntary Laboratory Accreditation Program) per
40 CFR 763.87. A list of labs can be found on ORCAA’s website.
3. The start date on other structure demolitions must be at least 10 working days from the submission date of the
complete application and payment.
4. It is the responsibility of the property owner and/or demolition contractor to ensure there is no asbestos-containing
material present in the structure to be demolished.
5. Any and all structures on the same parcel of property that are not proposed to be demolished must be identified as
such.
6. A copy of the asbestos survey and approved Demolition Permit must be kept on site and be available for review by
Agency inspection personnel.
7. The original demolition permit will expire 1 year from start date. If the permit expires and the project is not complete,
you must submit and pay for another demolition permit. Under no circumstances will a project be extended beyond 1
year from original submission date.
ADDITIONAL REQUIREMENTS:
In addition to Agency requirements, most building departments require a demolition permit (separate from ORCAA’s
Demolition Permit). The Washington State Department of Labor & Industries and the local fire authorities may also require
notification for asbestos removal projects.
”Owner Occupied Residential Dwelling” means any single family housing unit which is permanently or seasonally
occupied by the owner of the unit both prior to and after the proposed project. This term includes houses, mobile homes,
trailers, houseboats, and houses with ‘mother-in-law apartment’ or a ‘guest room.’ This term does not include structures that
are demolished or renovated as part of a commercial or public project; nor does this term include any mixed-use building,
structure, or installation that contains a residential unit, or any building that is leased or used as a rental, or for commercial
purposes.
Olympic Region Clean Air Agency
2940 Limited Lane NW
Olympia, WA 98502
(360) 539-7610 • FAX (360) 491-6308
South Bend Office (360) 942-2137
Port Townsend Office (360) 338-6419
www.ORCAA.org
Demolition Permit
Date Application Received
Agency Use Only
Payment Info.
[ ] Cash
[ ] Check: #___________
[ ] Credit Card
Receive date:___/___/___
Agency Use Only
[ ] Approved
[ ] Disapproved
Review date: ___/___/___
Reviewed by: ___________
Agency Use Only
Asbestos Permit
Permit # ____ASB00_______
Demolition Permit
Permit # ____DEM00_______
Agency Use Only
07/16 OVER
[ ] Owner occupied residential dwelling – Permit fee: $35.00 – Prior Notice - Nonrefundable
[ ] Other Structures – Permit fee: $61.00 – 10 working day wait period - Nonrefundable
[ ] Emergency Fee $51.00 – must be accompanied by Government Ordered Declaration (other structures only)
PROPERTY OWNER
Name:
Phone: ( )
Email:
Mailing Address:
City:
State:
Zip:
Site Address:
City:
County:
Zip:
DEMOLITION CONTRACTOR [ ] Check if same as property owner information.
Business Name:
Phone: ( )
Email:
Onsite Contact:
Phone: ( )
Email:
Mailing Address:
City:
State:
Zip:
DEMOLITION INFORMATION
# of structures being demolished:
Start Date:
Expiration Date:
Asbestos present? [ ] Yes [ ] No
Survey attached? [ ] Yes [ ] No
Has all identified asbestos been
removed? [ ] Yes [ ] No
DEMOLITION PROJECT CATEGORY
[ ] Complete Demolition
[ ] Training Fire – Fire Agency, Contact, Phone: ___________________________________________________________
[ ] Renovation, Alteration, Remodeling, Maintenance, or other Construction
I do certify that I am the owner, authorized agent of the owner, or authorized contractor for the property subject to this ORCAA application/permit. I authorize ORCAA
staff to enter the property listed in this application at reasonable times for purposes of inspecting the work that is the subject of this application/permit and to ensure
compliance with permit conditions, applicable laws and regulations. I understand that granting of this permit by ORCAA does not authorize anyone to violate federal,
state, or local laws or regulation pertaining to activities associated with this permit. I have read and will abide by the conditions set forth in this permit and any
addendum thereto.
I do certify under penalty of perjury under the laws of the state of Washington that the information in this application and supplemental data is, to the best of my
knowledge true, accurate and complete.
_____________________________________ ______________________________________ __________________
Applicant Name Signature Date
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DEMOLITION PERMIT APPLICATION

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Completed 18 April 2022

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