application Office Use Only
• DEMOLITION APPLICATION Permit#: ', lv -O G Zc(- ( /
((�� (� (� (� ��/ (� �1'-4ermit Fee:$ `G c o; DO
Town of Queensbury D L5 V� L� IJ V LS I voice:#: I A c f
742 Bay Road, Queensbury, NY 12804 `
P: 518-761-8256 www.queensbury.net JAN 2 2 2019
TOWN OF QUEENSBURY
BUILDING&CODES
Demolition Location: 26 South Western Avenue Tax Map ID #: 309.7-1-54
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): Richard E. Jones Associates Architects
Mailing Address, C/S/Z: 339 Aviation Road, Queensbury, NY 12804
Cell Phone: ( 518 ) 791-1960 Land Line: ( 518 ) 793-1015
Email: richardjones@rejaarchitects.com
• Primary Owner(s):
Name(s): Hudson Headwaters Health Network
Mailing Address, C/S/Z: 9 Carey Road, Queensbury, NY 12804
Cell Phone: _( 518 ) 857-3408 Land Line: ( 518 ) 761-3000
Email: dvalentini@hhhn.org
• Contractor:
Business Name: Orion DES
Contact Name(s): Joseph Loudis
Mailing Address, C/S/Z: 8D Petra Lane, Albany, NY 12205
Cell Phone:_( 518 ) 669-3723 Land Line: ( 518 ) 250-5658
Email:
Contact Person for Building & Code Compliance: Richard E. Jones, Architect
Cell Phone: ( 518-791-1960 Land Line: ( 518-703-1015
Email: richardjones@rejaarchitects.com
Demolition Application Revised June 2017
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? Green Ridge RDF, 424 Peters Rd., Gansevoort, NY
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 X
b. Fuel Oil
c. Propane
d. Electric X
e. Public Water X
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: Richard E. Jones
SIGNATURE: pabG g DATE: 01/18/2019
Demolition Application Revised June 2017