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2. Business Name (Contractors Only)
3. Business Phone Number*
5. Business Address
   Street Address, City, State, Zip
7. Applicant's First Name*
8. Applicant's Last Name*
10. Applicant's Phone Number*
11. Applicant's Email Address
13. Address to be demolished*
15. Asbestos Survey Documentation

    1. Complete (Documentation must be submitted)
17. Asbestos Abatement Documentation: If Abatement is necessary, documentation must be submitted.

    1. Abatement Complete (Removal Permit Required From Health Dept.)
    2. Abatement not necessary
19. Rodent/Pest Survey Documentation (Treatment must be within 3 weeks of demo)

    1. Complete (Documentation must be submitted)
21. Removal of all mercury-containing items (thermostats, etc.)

    1. Complete
23. Dumpster on site? If so, a permit is required from the Health Dept.

    1. Yes, dumpster on site
    2. No, trucking out debris
25. Dust Mitigation measures must be taken during demolition.
27. Was this hone built before 1978? Dust from lead-based paint can be a danger to the health of workers and people, especially children who live near by; therefore, dust control measures are important to take during demolition.

    1. Yes
29. Provide a written dust mitigation plan below, stating what measures will be taken.*
31. Name of demolition contractor:*
32. Cell Phone Number:*
34. Demolition Company Name*
36. Signature of contractor attesting that all items above have been addressed. By typing in your name, it will be considered an electronic signature.
    Insert Name & Date
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field