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application Office Use Only 71;; DEMOLITION APPLICATION Permit#: LYIY1<,)— (�(3e4--2 0d, Permit Fee:$ 1.3(2. 190 E In Town of C�ueensbuiy_.y C� r5f ( 742 Bay Road, Queensbury, NY 12804 P: 518-761-8256 www.queensbury.net MAR ,Z O 2019 TOWN OF QUEENSBURY • BU LDING&CODES P ' / Demolition Location: ler ii ,i'e)j� (if iL /Vr ax a i i . L , l//0 —! **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS** CONTACT INFORMATION: • Applicant: I Name(s): W f/,9 J / W/9/S/4 Mailing Address, C/S/Z: _7 // i`�.,K, // 9/4 Cell Phone: (:37? ) ? 7 6,/8 Land Line: ( ) /V0/s2_ Email:a, ,//2 /, /<S/ : l© � ' //I A ` e)Al O A o"' A(/ ,7' • Primary Owner(s): Name(s): /. � // r /9-,-,7 _7-- // Mailing Address, C/S/Z: ,7, A! J) // i7ri kr, ` l'fr C97-sri e- ,tl ,MI- Cell Phone: _(51( ) 9 9 �,"�1� Land Line: _( ) Email:.. 4'e -2'6�?�f/ e ` ea Ai , , e CI Check if all work will be performed by homeowner only • Contractor: Workers' Comp documentation must be submitted with this application Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: Cell Phone:_( ) Land Line: _( Email: **List all additional contractors on the back of this form Contact Person for Buildingi& Code Compliance: f /7, ./9 7 / 1 ' /'f Cell Phone: _rte) %L9' Ca 2/ Land Line: _( Email:. em .4 ' ")+ Demolition Application Revised February 2019 DEMOLITION INFORMATION: 1. Where will demolition material be disposed? 2. Type of structure to be demolished: a. Residence b. Garage f A_62, 7i.) c. Business d. Storage Building 3. What type of utilities are connected to the structure: a. Gas b. Fuel Oil c. Propane d. Electric e. Public Water f. Well-Water Pump g. Public Sewer h. Other i. None 4. Have ALL utilities been disconnected? Yes . No 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. 3. Workers' Comp insurance information is required to be submitted with this application. 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: Z/11, '///#9 7 Ln " 2"�')✓✓ / /� SIGNATURE: � �2'��� �-'Ci i� � 6 � � DATE: /�'�O/ Demolition Application Revised February 2019