application Office Use Only
DEMOLITION APPLICATION Permit#: ;7�ma— D( ( L - /
!_ �, Permit Fee:
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742 Bay Road,Queensbury, NY 12804
P:518-761-8256 www.uueensburv.net MAR 0 8 2019
TOWN OF°OUEENSPURY
BUILDING a w=
Demolition Location: 1 -Tax Map ID#: �j��c� I I(_(`S
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): '(Anf--,M `\Q
Mailing Address, C/S/Z: 1 3 P•1�(.he r i2 d C Q Q n`-4or-1)\ ley 10 SLT
Cell Phone: ( DI`% ) �j.�� - ( o Land Line: ( rj; )`7 � _]-1 Lo
Email:
• Primary Owner(s):
Name(s): Fi c P
Mailing Address, C/S/Z: f3 P r\ C_Ihr`= i 12 LxC On-A-) >~-`IYA N 1 ) % SC,-/
Cell Phone:_(_ ) Land Line: _( l S )-71-1 ~i° 7"7 L ?
V\ S k ? CU(-'(---"\-LI 5 CC) r'Yl
• Contractor:
Business Name:C rrb`, -71 'J C.' , n �
Contact Name(s): C r l i F Cb m b.S
Mailing Address, C/S/Z: CitQ '`' n t U Q r it A , CAL e 1tA NY Y 1 g U -i
Cell Phone: _(5 1'i ) 1ea - 7 Land Line: _( )
Email:
Contact Person for Building & Code Compliance:A GtC(�l ( �, �i V1 0 ptt
Cell Phone: _(51 ) , j 39--Jq to Land Line."" ( F ) '7415-17-1 (,..0
Email: Tort 31-pcw Lo. 11"vp--p rbp7ey-t i-en , cL_ }
Demolition Application Revised June 2017
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? ( ( \' LA k.A
2. Type of structure to be demolished: 0-10.0L)-(CLC41.)fe 1--)n rrv�?,
a. Residence
b. Garage
c. Business
d. Storage Building
3. What type of utilities are connected to the structure:
a. Gas
b. Fuel Oil A/
c. Propane
d. Electric ."
e. Public Water v.'
f. Well-Water Pump
g. Public Sewer
h. Other
i. None
4. Have ALL utilities been disconnected? Yes No
ADDITIONAL INFORMATION:
1. Two inspections may be required: an inspection to determine that utilities are disconnected, if
necessary, and a final inspection, after the structure is removed and the site is cleaned up and graded.
2. Twenty-four(24) hour notification is required for inspections.
Declaration:I acknowledge that no structure(s)will be removed from the parcel until the demolition application has
been reviewed and approved by the Town of Queensbury Building& Code Enforcement and Zoning Departments and a
permit has been issued.
I have read and agree to the above:
PRINT NAME: prn j no () - ���5)
SIGNATURE: (ilyki j> 1 ' 7(( . f .( a DATE: /,`,25)
Demolition Application Revised June 2017