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DEMOLITION APPLICATION Permit# 111-0I 0
Permit Fee:$ , bO
Town of Qyeensbury
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742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.dueensburv.net
MAR 0 8 2019
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Demolition Location:1--1 ) .
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**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): A n C
Mailing Address, C/S/Z: 1 cl &C,20nnhn.4 N 9,S 04
Cell Phone: ( 1 (S Land Line: ( - -71 -7L0
Email:
• Primary Owner(s):
Name(s): ruck) 2'0- 1-1\
Mailing Address, C/S/Z: Cke ç c\ . 00,e nhurLiNV <7501
Cell Phone: ( Land Line: (`31 ) '7"--7 Lc.
Email: C T-Ts`s,, Om? c
• Contractor:
Business Name: Cr.,t —VA CX I neA
Contact Name(s): c " re. C&rb3f)
Mailing Address, C/S/Z: Vo.ii Ce..r) WI Qcyaio rciloc‘flAla st)44
Cell Phone: ( cis ) 10)a- -1 5'Zs' Land Line: ( )
Email:
Contact Person for Building & Code Compliance: )7)6,44 be
Cell Phone: ( jC I u Land Line:3e5) ) 7 --I-7 .o
Email: fIf e {fork.k < e - i4-A V \-La cogiA
Demolition Application Revised June 2017
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? Co v)
2. Type of structure to be demolished: POOL—n >-CGc_C- ore c4) o ry
a. Residence
b. Garage
c. Business
d. Storage Building
3. What type of utilities are connected to the structure:
a. Gas
b. Fuel Oil ✓
c. Propane_
d. Electric v/
e. Public Water V
f. Well-Water Pump
g. Public Sewer
h. Other j c } i
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: Pi r)Y) gC(,S
SIGNATURE: CC, ItY/97V- A�t�tj �y DATE: ;/9�j )9
1
Demolition Application Revised June 2017