application Office Use Only
v f. DEMOLITION APPLICATION Permit#: D U - 610 1 - 2t'(
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742 Bay Road, Queensbury, NY 12804
P:518-761-8256 www.queensbury.net
11 MAR 08 201 ,
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Demolition Location:I�`-j �►�,��n0c- , je
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): 1::\- nn\ -Ci€ VCC ► 7)
Mailing Address, C/S/Z: 1 . QC C.n` i(i'Z NY 1 (`
Cell Phone: (Y.j)Z - C } Q Land Line: ( rS i Z ) • 77
Email:
• Primary Owner(s):
Name(s): FEy PCkC
Mailing Address, C/S/Z: PAc hec 2-6 CZ)oeo v'/ 19 ZY
Cell Phone: _( ) Land Line: ( % )'7'-1 ' J O
Email: OCe2-1- C').0 c c1-•, - 91cr)e (4 i . c -r m
• Contractor:
Business Name: Cbry4) \'Y11)(1 1 r)C\
Contact Name(s): C.hCACli e CCi Y \r 3
Mailing Address, C/S/Z: gut Nan C, : ( o{) 0 n bori NN ) dij(0'1
Cell Phone: _(`j i ) icia - 5 -1 �" Land Line: ( )
Email:
Contact Person for Building & Code Compliance: niQCCt C 0l21("!G`�'1
Cell Phone: (f I ) Land Line. ( 5J g )-7 -1 j- 1-1-7
Email: (t:1r t Of.t k Y t 0)(4404)4,J Ocryl
Demolition Application Revised June 2017
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? (,01-1'1`\- LA Locl.`54 e
2. Type of structure to be demolished: 11"m0;,--)LycGc C ( to hG
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 V
d. Electric v`
e. Public Water v°A
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: Yl V� r 1 )(4 ( i e
SIGNATURE: (trfr Ar)0 A ,{D., DATE: ' awe 5)
Demolition Application Revised June 2017