application it n
I u JUN 2 6 201� i 'eU o '
pe4it#: U'Q G 7 ZDEMOLI . ON APPLICATION..) L>"11 ,,/1 1
I'OL'Ui'l OF CUE NSBtJt '`Perrrtit fee:$ j S �. OD
Town orQuccn sbun BUILDING CODES ��� 1
•-Siam* I 73 J
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensburv.net
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Demolition Location: /0(l 41/1 re.1 Tax Map ID#: L.19,/11;5--
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): Frank Marshall
Mailing Address, C/S/Z: 211 Church Street,Saratnp Springs NY 12R66
Cell Phone: ( 518-70t4-4448 Land Line: ( 518-5$0-2679
Email: fmarshall@saratogacare.org -
• Primary Owner(s):
Name(s): The Saratoga Hospital
Mailing Address, C/S/Z: 211 Church Street,Saratoga Springs,NY 12866
Cell Phone:_( ) Same Land Line: _( ) same
Email: same
El Check if all work will be performed by homeowner only
• Contractor:V�grkers'Comi 4ocym ntation must be submitted with this application
Contact Name(s): rvI t' n I /
Contractor Trade: 67/4„.r.61141
Mailing Address, C/S/Z: p�/.� t S3 //r1�ir.i A NV veN
Cell Phqne:_( _) 6,tel i70d' Land Line:(,571 ) 7ff- Dr/� ,C/2
Email:Arra/x-AuS�S�ived -didinib . Got-+
**List ail additional contractors on the back of this form
Contact Person for Building & Code Compliance: �p/.tC' A)
Cell Pho : ( y, Nei- Land Line: _( t ) 74,E-2 W it. //
Email: tali. A _ ,_ 1(1/1U - i-l-1 . 604Xi
Demolition Application Revised February 2019
rs'
DEMOLITION INFORMATION: 4,419..i/eoft
�//��1. Where will demolition material be disposed? WG� {.
2. Type of structure to be demolished:
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
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: Frank Marshall V2\51/
SIGNATURE: DATE: 9
Demolition Application Revised February 2019