Do I need a notary for the PCBs Screening Assessment Form – Part 1?

No. The form calls for signatures and dates from the property owner or representative and, if applicable, the consultant. If Questions 1–3 require Part 2, submit that separate form with the demolition permit application.

How do I submit the PCBs Screening Assessment Form – Part 1?

Submit the completed form to the Building Department with the demolition permit application. If the screening answers require Part 2, submit that form with the application too.

Do I need a separate form for each building?

Yes. The form says to complete one form for each building to be demolished.

Campbell, CA · Santa Clara County

No notary required

PCBs Screening Assessment Form – Part 1

Demolition permit applicants use this form to screen a building for PCBs in priority building materials and certify the information provided.

What this form is

Demolition permit applicants must complete this screening assessment to check whether a building may require further PCBs screening for water quality protection. The form asks for project, owner, and optional consultant details, construction type, answers to screening questions, and signed certification. Complete a separate form for each building being demolished; Part 2 may also be required based on the answers to Questions 1–3.

Who needs it

Applicants for demolition permits complete this form for each building to be demolished and certify the information provided.

How to submit it

Submit the completed form to the Building Department with the demolition permit application. If Questions 1–3 require it, submit Part 2 with the application as well.

About notarization

This form is signed and dated without a notary; if Questions 1–3 require Part 2, obtain that separate form and submit it with the demolition permit application.

How to submit this form

1
Download The Form
Download PCBs Screening Assessment Form – Part 1.
2
Complete The Assessment
Enter project and owner details, select the construction type, answer Questions 1–3, and complete the certification.
3
Gather Any Required Form
If Questions 1–3 indicate it is required, obtain PCBs Screening Assessment Form – Part 2 from the Building Department.
4
Submit The Forms
Submit the completed form, and Part 2 if required, to the Building Department with the demolition permit application.

Frequently asked questions

Do I need a notary for the PCBs Screening Assessment Form – Part 1?: No. The form calls for signatures and dates from the property owner or representative and, if applicable, the consultant. If Questions 1–3 require Part 2, submit that separate form with the demolition permit application.
How do I submit the PCBs Screening Assessment Form – Part 1?: Submit the completed form to the Building Department with the demolition permit application. If the screening answers require Part 2, submit that form with the application too.
Do I need a separate form for each building?: Yes. The form says to complete one form for each building to be demolished.
What information does the form ask for?: It asks for project, owner, and optional consultant information, construction type, answers to screening questions, and certification signed and dated by the required parties.

Need something notarized?

This PCBs Screening Assessment Form – Part 1 doesn’t need a notary — but if you have another Campbell form that does, a commissioned online notary can help.