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application
Office Use Only DEMOLITION APPLICATION|"="™**CARA) permitfee:$\OO7AaInvoice:#:22252: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Demolition Location:1477 Rt9 Tax Map 1D #:_286.\-5) **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATIO J SSIONS** CONTACT INFORMATION: TOWN OF QUEENSBURY©Applicant:BUSING NeuName(s):_Jackson Dem Mailing Address,C/S/Z:_397 Anthony St,Schenectady NY 12308 Cell Phone:_()Land Line:(518 _)_374-3366 Email:_chodgkins@jacksondemolition.com ion Service Inc. ¢Primary Owner(s): Name(s):MT.Assccsmnes ~Trae “Teomnerra Mailing Address,C/S/2:217A.Maw St Ruveay VT OS?DO Cell Phone:_()Land Line:_() Email:Fadux @ Mtdwhyop.BLE O Check if all work will be performed by homeowner only «Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):_Jackson Demolition Service Inc. Contractor Trade:Demolition Mailing Address,C/S/Z:397 Anthony St,Schenectady NY 12308 Cell Phone:_()Land Line:_(_518_)_374-3366 Email:_chodgkins@jacksondemolition.com **List all additional contractors on the back of this form Contact Person for Building &Code Compliance:Cuiges _Hopgazus Cell Phone:_($78_)761-3934 Land Line:_($1 _)374-3366 Email:_C topGervs@ She wsow Dinan pion Conn emalition Application Revised February 2019 DEMOLITION INFORMATIO! 1.Where will demolition material be disposed?Approved landfill for ACM,Clean C&D and hardfill 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: Gas _X_ Fuel OilPropane___Electric _X. Public Water _X_ Well-Water Pump ___Public Sewer __Other i,None 4,Have ALL utilities been disconnected?Yes _X No Fermeaoge ADDITIONAL INFORMATIO! 1.Two inspections may be required:aninspectiontodeterminethatutilitiesaredisconnected,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. :|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. |have read and agree to the above: PRINT NAME:CHRD.Hove aru SIGNATURE:OE DATE:W 2b 4 Demolition Application Revised February 2018