application Office Use Only
"tr Permit#: Dein - AC1
DEMOLITION APPLICATION
Permit Fee:$ /
I sn a(zyc,n,bun
Invoice# 1 2_767
742 Bay Road, Queensbury, NY 12804
P:518-761-8256 www.queensbury.net
I MAR 0 8 2019
TOWN OF CljEE.N3U,JRY-7
Demolition Location: 31CcQc , C_A
it/-/-**AN ASBESTOS ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): 'n(Y),C )e
Mailing Address, C/S/Z: C k(-)X VA . (NA.)(3 OncjY)C/1-1A NN/ )9 SU-i
Cell Phone: (c1)`.6 ) (eg. ‹,3L0 Land Line: ( ciS• ) -145
Email:
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: c5c--\C A ro,oe n -31,-) ) ) ( i
Cell Phone:_( Land Line: ( )"7`43P---5 - Ts?-7L7
e Tmoc1Q . Ccrvm
• Contractor:
Business Name: Oyy\- Vcoc nG\
Contact Name(s): (- ) ()()(y)b
Mailing Address, C/S/Z: VCAn r7 )? A . 0 Kf. bt)1-1,k NY I Y-1
Cell Phone: ( ) re-) - c.5 X Land Line: ( )-)
Email:
Contact Person for Building & Code Compliance: nlaCie ( al Lacil
Cell Phone..., (51 ) 10 Land Linei' (511 ) 7LI5 ? T7t
Email: -1(.1.-c pctirk(: rhp-pmpo-ti e e_c,Or)
Demolition Application Revised June 2017
DEMOLITION INFORMATION:
1. Where will demolition material be disposed?_ O.01,--)4 lAp(,t .>�-'
2. Type of structure to be demolished: rm.(;-►U Gs.C D1 h o YY-i
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
d. Electric v-,.
e. Public Water ``�
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: P y 1 I)( ► , ( )C
•
SIGNATURE: -Yr,,- .In it. ,g(Q- DATE: j0 -c--.QD, J ) I j
Demolition Application Revised June 2017