application Office Use Only
DEMOLITION APPLICATION Permit#: DEMO - °ot6- 2Zek�
Permit Fee:$ 150 ADO
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Invoice:#:
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net
Demolition Location: (,jd'L Gt-eh S - cif` Tax Map ID #: 30 2-- '4 -I- 2t
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): PInc.Sc_ Zcv D cs1 J„
Mailing Address, C/S/Z: 3 S Po,d P -l. (Li /4�� l�w.•, /hA oaoY3
Cell Phone: (G (7 ) 9 3 7 -3 Go G Land Line: 7):i ) y5 a • 7/ 1
Email: L S;ro' s h� s� Zcro dcs'ln . co.-)
• Primary Owner(s):
Name(s): 0' 9—c.2,1\-r
Mailing Address, C/S/Z: .2 3 3 ,5„4A.. Psi-# .-sow, S p,•:h� P cla p, o 4 S toa,
Cell Phone: _( ) Land Line: (y /7 ) ?, • G 74
Email:
• Contractor: E O V E ;
Business Name: T (3 A
Contact Name(s): MAR 01 2018
Mailing Address, C/S/Z: _ J
Cell Phone: _( ) Land Line: ( ) TOWNOFQUEENSBURY
Email: BUILDING&CODFS
Contact Person for Building & Code Compliance: a
Cell Phone: Land ie: ( d'r ) yS.Z • 7/ .2 /
Email: L . 'Ukt-Q
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Demolition Application 201 ` ` R
�� Revised June 2017
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DEMOLITION INFORMATION:
1. Where will demolition material be disposed? T' ,O — w^,1\ k,c_, Co vnott... .
2. Type of structure to be demolished: On cc. A D e-• con
a. Residence has , e.-• s
b. Garage
c. Business ,C
d. Storage Building e-\ev 2oc --
3. What type of utilities are connected to the structure: ;fir,►-,-mac-.vAt
a. Gas
s.\
b. Fuel0i Va �vL.Ce.,1s ct;oY•
c. Propane
d. Electric X
e. Public Water x
f. Well-Water Pump
g. Public Sewer I,
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: L a ccLn ;.S
SIGNATUR . (ice s—� L'"�-�— DATE: p2 ' 2B ' /B
Demolition Application Revised June 2017