application P. .
Office Use Only
DEMOLITION APPLICATION Permit#: f)-6440'0?GZ - Zo/o
2 ( L5 a
[ rE 0 nor req:$ f Q U
Town of Queen .ury D i t Z Z
I aver:
742 Bay Road,Queensbury, NY 12804
P:518-761-8256 www.queensbury.net 1 NOV 0 6 2018 J
TOWN OF QUEENSBURY
p8, ad
,4 J ILDING&CODES 'M. /Demolition Location: Q /r ax apt p1 '/. "/"/
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• A li nt:Name(s): V/CQJ 0479.
/
Mailing Address, C/S/Z: �/f /t , Sfree �A 4,1 1c`/ A// //la
Cell Phon : 37f ) 36/-6,a Land Line: LI-7J ) 795-w,5/
Email: C i.ek is J 3Q rv1GJ -l4Ibf/%a7 l'G111
• Primar Owners : /
Name(s): _/ / e (-76,1 /t/
Mailing Address, C/S/Z: /// £/gP //7 e! 6Zr..) /A /`r' /J,'
Cell Phone: _( 37d t ' Z, - �� 7 Land Line: _(.57J ) �l1/-,Jd?5`0 x' A,4
Email: �y"yiHe_/ �v /'i 46 Leff,4/4. /`/
• Contractor:-)
Business Name: c3pr✓d.e/ //✓/ �.i.7//4/
Contact Name(s): /?/li ./-G
Mailing Address, C/S/Z: J/3 /'y/z f2 z// % I /J /l AiV /JAG/
Cell Phone _( 7J ) is/Da�/12 Land Line: _( ,_57t ) 743 'iG Vi/
Email: may[/-/d%0 ,sC?Pr'✓/Ce.1 -iii ki ,A/ 6/.,-'
Contact Person for Building & Code Compliance: • /-(k. 210
Cell Phon _( ) 3 /-Ga 7 Land Line: _( d_ ) -79,3 -7DW
Email: do-.e _ Le ( e rieiO 1 -vim iie la. C'er1
Demolition Application Revised June 2017
•,
DEMOLITION INFORMATION: üIa
1. Where will demolition material be disposed? �Y
2. Type of structure to be demolished: J
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.
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: 1-1 *) Lc;
SIGNATURE: DATE:
Demolition Application Revised June 2017