Windom, MN

Application for Demolition Permit

Site Address*

Street Address

Address Line 2

City

State

ZIP Code

Applicant Information

Applicant's First Name*

Applicant's Last Name*

Applicant's Phone:*

Applicant's Email:*

Applicant's Address*

Street Address

Address Line 2

City

State

ZIP Code

Is the Applicant the Same as the Owner?*

Yes

Contractor Information

Contractor First Name*

Contractor Last Name*

Contractor Phone*

Contractor Address*

Street Address

Address Line 2

City

State

ZIP Code

Excavation Contractor*

Excavation Contractor Phone*

Excavation Contractor Address*

Street Address

Address Line 2

City

State

ZIP Code

DESCRIPTION OF DEMOLITION:

Type of structure to be demolished:*

Start date of demolition:*

Completion date of demolition:*

Minnesota Statutes Chapter 216D requires that the EXCAVATOR must call GOPHER STATE ONE-CALL at 1-800-252-1166 at least 48 hours before beginning any excavation. It is important to avoid striking any underground utility, telephone, cable television or water and sewer lines. Hand digging is required when excavating within two feet of the markings.
IMPORTANT: By signing this document, I am indicating that I have received this notice and agree to accept responsibility for either calling Gopher State One-Call or notifying my excavator to call 48 hours prior to excavating.

APPLICANT'S CERTIFICATIONS AND COMPLIANCE*

I agree

I hereby certify that I have read, examined and completed this application and know the same to be true and correct. I accept responsibility for compliance with all applicable laws, notifications, and city provisions, including those noted on the attached MCPA handouts. The granting of this permit does not authorize violation or cancellation of any state or local law regulating demolition or the performance of demolition.

Applicant Signature*

Permit Fee:

Price:

Credit Card Surcharge
Price: $1.88
Total Amount Due:
$51.88

Card Number

Expiration Date

Security Code

Cardholder Name

Days	Hours
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Days

Hours

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

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Applicant Information

Contractor Information

DESCRIPTION OF DEMOLITION:

Catalogue title

Article Title

Job post

Job Position

Bid details

Bid Title