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2. CITY OF FAIRBURY, NEBRASKA

   APPLICATION FOR DEMOLITION PERMIT

4. DATE:
5. FEE: $20.00
7. OWNER:
8. CONTRACTOR:
10. HOME ADDRESS:
11. ADDRESS:
13. CITY, STATE, ZIP
14. CITY, STATE, ZIP
16. TELEPHONE:
17. TELEPHONE:
19. ADDRESS/LOCATION WHERE WORK TO BE DONE:
21. LEGAL DESCRIPTION:
23. LOT
24. BLOCK
25. ADDITION/SUBDIVISION
27. OR LEGAL DESCRIPTION:
29. TYPE OF BUILDING/STRUCTURE:

    1. RESIDENTIAL

    1. COMMERCIAL

    1. INDUSTRIAL

    1. ACCESSORY
31. ACCESSORY (TYPE):
33. BUILDING/STRUCTURE SIZE:
35. NO. OF STORIES:
36. NO. OF DWELLING UNITS:
38. FRAME TYPE:

    1. WOOD
    2. OTHER

    1. CONCRETE

    1. STEEL

    1. BRICK
40. DISCRIPTION IF OTHER:
42. UTILITIES DISCONNECTED:

    1. WATER
    2. SEWER
    3. OTHER

    1. GAS
    2. TELEPHONE

    1. CABLE (TV)
    2. ELECTRIC
44. IF OTHER DISCRIPTION:
46. ASBESTOS (IF ANY) REMOVED:

    1. YES

    1. NO

    (when required, proof of inspection and proof of removal by certified contractor and 10 day notification to DEQ and NE Department of Health & Human Services)

48. DATE DEMOLITION WILL BE COMPLETED:

    (60 days from insurance as specified in Sec. 4.12, Fairbury 2005 Zoning Regulations)

50. The property owner will be responsible to maintain barricades around the site until the structure is completely demolished. If, after demolition, it is found that a basement hole requires filling, and the job is not completed within daylight hours, the property owner will place barricades surrounding the area until the hole is cleared of debris and completely filled. If any damage is done to city sidewalks, alleys, streets or utilities, the property owner will be responsible for repair or cost of repair for such damages.

    The property owner shall be responsible to clear streets and alleys of debris each day.

    The property owner shall be responsible for the disconnection of the City water service line and capping of the City sewer service line and pay for the costs of any work affiliated with the disconnections. The City water service shall be disconnected at the City main. the City sewer line shall be capped at the property line. The property owner will pay a deposit of $300.00 to ensure completion of such work. The work shall be inspected by City personnel BEFORE proceeding with demolition and AFTER work is completed. The deposit will be forfeited and the money applied to repair any damages to City property and/or any necessary work performed by City personnel on disconnections unsatisfactorily done by the property owner.

    The property owner shall notify the Fairbury Utilities Department and any other utilities (natural gas, telephone, cable TV, Diggers Hotline [800-331-5666], etc.) prior to actual demolition in order to ensure meters or any other devices have been removed and/or located.

    
    

52. I do hereby certify that the above required information is true and correct to the best of my knowledge and all actions will be performed in accordance with all provisions of the City Municipal Code and any other regulations.

     

    ___________________________________ 

      Applicants Signature

     

    The foregoing application was subscribed and sworn before me this

     _______ day of ________________, 20_____.

                                                                                                                    

    ______________________________________

    STATE OF NEBRASKA                                                   Notary Public

    County of Jefferson                                                    

                                                                                                    ___________________________

                                                                                                                    Commission Expires

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