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Demolition Application (2-7-2019) Page I 1 Public Utility Service Disconnection Permit Application A Public Utility Service Disconnection Permit is required as part of the demolishing of any building that is connected to water or sewer service. To request a Public Utility Service Disconnection Permit, please complete this application form and submit it to the City of Woodburn Engineering Department, Woodburn City Hall, 190 Garfield Street Woodburn, Oregon 97071 Section 1 – Applicant Information PROPERTY OWNER(S): Name(s): Mailing Address: Email: Phone Number: Cell Number: CONTRACTOR INFORMATION: Business Name: CCB#: Contact Name: Mailing Address: Email: Phone Number: Cell Number: Section 2 – Project Information Site Address: Type of Building: Is it listed on the National Historical Register or the City of Woodburn Historic Resource Inventory? Yes No Does the site have a re-development currently proposed? Yes No If yes; Contact the Planning department. If Commercial Building, please provide the existing meter size: Inches At least 48 hours in advance of beginning work: Call for utility location marking before beginning work (dial 8-1-1). Contact the City of Woodburn Water Department at [PHONE REDACTED] to request disconnection of service. Contact the City of Woodburn Public Works Staff at [PHONE REDACTED] to schedule a witness of work, inspection of the sealing and relocation of the sanitary sewer and storm sewer lines within five feet of the property line. Section 3 – Hazardous Materials Acknowledgement and Signature Section The City of Woodburn does not assume liability for any hazardous materials that may be on the premises that is the subject of this application. It is applicant's responsibility to comply with all laws relating to the identification, removal, handling, and disposal of hazardous materials. For information about hazardous materials, please contact the Oregon Department of Environmental Quality at (503) 378-5086 or 1-[PHONE REDACTED]. I hereby certify that, to my knowledge, the above information is true and correct. All work to be performed shall be in accordance with all governing laws and rules. Owner’s Signature Date: ---PAGE BREAK--- Demolition Application (2-7-2019) Page I 2 Section 4 - Approval Approved Denied Reason for Denial: Authorized Signature Date Final Distribution: Engineering Department Utility Billing