application Office Use Only
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DEMOLITION APPLICATION Permit#: -0l ' 2B\�
Permit Fee:$ 150
town of Opecnsbury
Invoice:#: 181-41
742 Bay Road, Queensbury, NY 12804
P:518-761-8256 www.queensbury.net
Demolition Location: .3Vk v c,��c� �c. Tax Map ID #: 308. )S - 1 r 58
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION
CONTACT INFORMATION: AUG 08 2019
• Applicant: TOWN OF QUEENSBURY
Name(s): 2)c7`3A.V\OVA- BUILDING&CODES
Mailing Address, C/S/Z: , a;" fjr/cby
Cell Phone: (SI6 )36,1-d93) Land Line: (
Email: clirk->a-WD5T Q ac,hi kor
• Primary Owner(s):
Name(s): Do,v, \kvy��
Mailing Address, C/S/Z: 3(' ISr'‘c\&ov p41,
Cell Phone: _( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: (
Email:
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: V c,,v� \kov\--\-
Cell Phone: (S/$ ) 3Cp(- 31 Land Line: (
Email:
Demolition Application Revised February 2019
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? fpc , v\ Vk/ /
2. Type of structure to be molished: (UT
Yp f le �� _1
a. Residence V 1-6"2 �" ��- ��vr\ V� -Q-ro
b. Garage 2. ( RYhOe� LSQ� r-Q.
c. Business
d. Storage Building
3. What type of utilities are connected to the structure:
a. Gas V
b. Fuel Oil
c. Propane
d. Electric f
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: O•Y\
SIGNATURE: DATE: 8 i1 / 9
Demolition Application Revised February 2019