No preview available
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