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09 209 |)+or y Office Use Only‘ sDEMOLITIONAPPLICATION_|Perm #:DEMO-048 -Bo1 Permit Fee:$_[50.07 Town of Queensbury tnvoice:t:_POSS 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Demolition Location:2 Puesei Q ‘Tax Map ID #: **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS** CONTACT INFORMATION: ant: Names}TH Geea\\ Mailing Address,C/S/Z: Cell Phone:_(SNO_)Bel -24+7 landline:(QB)192-2s Email:G@e@e>mnEMPe2acHomes .Com °Primary Owner(s): Name(s):Heap!e Noa Thee Mailing Address,C/S/Z:M CElEConEe azCellPhone:_()Land Line:_() Email: O Check if all work will be performed by homeowner only ¢Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):MH Gmpediar Home.etContractorTrade:@E0e2 BL — Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: **List all additional contractors on the back of this formAdieonpacyINDUSTHIES Contact Person for Building &Code Compliance:HenceCellPhone:(SID )Bll 345]Land Line:(Bi )JAL- Email:eae,G>MNEmPESDl Homes .Com) Demolition Application Revised February 2018, *Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s):ADIZGOORGKL INDUSTELES Contractor Trade:Sif woewk Demoitions Mailing Address,C/S/Z: Cell Phone:(ELD )464 -O13H land tine:_(BI®)TU-Q7ESEmail:_ADICOKOACH INDUSTRIES ©Amal acorn *Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s): Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_()land Line:_() Email: *Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s Contractor Trade: Mailing Address,C/S/2: Cell Phone:_()Land Line:_() Email:, *Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s): Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: *Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s): Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: ¢Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s): Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Demolition Application Revised February 2019 DEMOLITION INFORMATION: L wesmontghaonnes AcE Carri. 2.Type of structure to Ye demolished: a.Residence V_b.Garage___ c.Business d.Storage Building 3.What type of utilities are connected to the structure: a.Gas__ b.Fuel Oil ©.Propane Electric Zo Public Water d. e. f.Well-Water Pump. 8. h. Public Sewer |.Other i.None ities been disconnected?Yes No y ADDITIONAL INFORMATIO! 1.Two inspections may be required:an inspection to determine that utilities are disconnected,if necessary,andafinalinspection,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. :|acknowledge that no structure(s)will be removed from the parcel until the demolition application has wed and approved by the Town of Queensbury Building &Code Enforcement and Zoning Departments and a permit has been issued. |have read and agree to the above: PRINT name-Geeg,Heover sianaTure:_7*%4 DATE:Hoa 4 Demolition Application Revised February 2019,