Bookmark and Share

Deconstruction Project Assessment

It is the applicant’s responsibility to accurately document the building materials, appliances and contents found in each building and provide a summary of the disposition of those materials during the deconstruction project. Failing to complete this form will delay issuance of permits.


 

Owner & Property Information


Application date:     Address:   

Year built:    Owner:   

Owner's phone number:
 


 

Contractor/Consultant Information
 

Name:   

Certification #:   Phone:

Select one:

Method to be used to deconstruct:

Anticipated start date (00/00/2017) of deconstruction: 

Anticipated end date (00/00/2017) of deconstruction:


 

Exemption


Request for exemption:  Yes      No

Reason for request:

 



Please describe condition or if hazardous materials are present for each item below.
 

MATERIALS

Appliances:  Yes   No     Reuse    Repurpose    Recycle    Landfill

Cabinets:  Yes  No     Reuse    Repurpose    Recycle    Landfill

Doors:   Yes  No       Reuse    Repurpose    Recycle    Landfill

Electrical:   Yes  No      Reuse    Repurpose    Recycle    Landfill

HVAC:   Yes  No     Reuse    Repurpose    Recycle    Landfill

Lighting:    Yes  No     Reuse     Repurpose     Recycle    Landfill

Hardware:   Yes  No     Reuse    Repurpose    Recycle    Landfill

Plumbing/Pipes:  Yes No     Reuse    Repurpose    Recycle    Landfill

Sinks:  Yes No     Reuse    Repurpose    Recycle    Landfill

Toilets:  Yes  No     Reuse    Repurpose    Recycle    Landfill

Tubs:  Yes  No     Reuse    Repurpose    Recycle    Landfill

Windows:  Yes  No     Reuse    Repurpose    Recycle    Landfill

Wood Flooring:   Yes  No    Reuse    Repurpose    Recycle    Landfill

 

LUMBER

Framing:   Yes  No     Reuse    Repurpose    Recycle    Landfill

Trim:   Yes  No     Reuse    Repurpose    Recycle    Landfill

Sheathing:   Yes  No     Reuse    Repurpose    Recycle    Landfill

Siding:   Yes  No     Reuse    Repurpose    Recycle    Landfill

Other:  Yes  No     Reuse    Repurpose    Recycle    Landfill

 

ROOFING

Asphalt:   Yes  No     Reuse    Reporpose    Recycle    Landfill

Slate/Tile:  Yes  No      Reuse    Repurpose    Recycle    Landfill

Metal:  Yes No     Reuse    Repurpose    Recycle    Landfill

Masonry:  Yes  No      Reuse    Repurpose    Recycle    Landfill

 


 


Interior Finishes - ceiling, walls, floor (plaster, drywall, drywall over plaster, carpet, tile, etc.):

Estimated weight of recyclable concrete materials:

List any excessive contents (furniture, clothing, personal items) and provide a brief statement as to how it will be handled:



 


 

I understand that this application must be reviewed and approved through a site inspection with DNS staff prior to the issuance of a permit to raze.

I understand that all documentation for materials removed from the structure must be maintained throughout the deconstruction project and copies must be submitted to DNS in order to close the raze permit at the end of the project. 

I agree to post signage per the requirements of the Administrative Rules of Deconstruction effective January 1, 2017. 

 

Name 

Name required as signature acknowledgement.