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application I
Office Use Only
DEMOLITION APPLICATION Permit#: O�MO— eftZO
Permit Fee:$ 4r-DO
Town of(Zuccfi.bury
Invoice:#: �U
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net
Demolition Location: 3bcl 1)tXohl 1) Tax Map ID #:
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:.
Name(s): ',t 1/(JJ 7boa j,nnt.�
Mailing Address, C/S/Z: 1 W-r.),w4-( C7t
Cell Phone: ( c1'O ) 233" Land Line: ( S'/c3 ) -741 — 97 7S
Email: C4 At4 f cL) //vodovrinimis//c. 62
• Primar Owners : E 1 `7
Name(s): -<- Wou,t,4 ,�.
Mailing Address, C/S/Z: JUL 2 3 2019
Cell Phone:._( Land Line: _( ) TOWN OF QUEENSBURY
Email: BUILDING&CODES
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be su mitted with this application
Contact Name(s): /a-1L-t.S1/o.-e XeciAreA.4 cfA ( SR.-.72ooD “_ts
Contractor Trade: °c t/crt-ion
Mailing Address, C S/Z:
Cell Phone: _( 5 ) goo/ — 6/C7 Land Line: _(
Email:
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: IMVCAnaQ.]
Cell Phone: (5112) ) -]41-1 — 'Z 3- Land Line: (
Email:
Demolition Application Revised February 2019
DEMOLITION INFORMATION:
A
1. Where will demolition material be disposed? c'2' ` t.tAtot Nr4
2. Type of structure to be demolished: L
a. Residence
b. Garage2(
c. Business
d. Storage Building
3. What type of utilities are connected to the structure:
a. Gas
b. Fuel Oil
c. Propane
d. Electric
e. Public Water
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.
3. Workers' Comp insurance information is required to be submitted with this application.
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: Iw‘-L 4—� Settn,[ve_S
SIGNATURE: DATE:
Demolition Application Revised February 2019