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application
Office Use Only DEMOLITION APPLICATION Permit#: _ �Z�eA- -2.0 Permit Fee:$ Town of Queensbury Invoice:#: lAtelt 742 Bay Road, Queensbury, NY 12804 P: 518-761-8256 www.queensbury.net Demolition Location: ® cf1012L\,<. - v<- Tax Map ID #: c1 **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS** CONTACT INFORMATION: • Applicant: Name(s): Mailing Address, C/S/Z: tree',(. Cell Phone: (67F• ) 7'f'Y f-133Z Land Line: (5/7 ) `74/5-5-73 Email: - 6 7 Nr'R-\\ • Primary Owner(s): Name(s): MCA-t,r„-1?s.0 trsk t Mailing Address, C/S/Z: 54t Gcr,L<. ct,4" Cell Phone: _( ) Land Line: _( Email: ❑ Check if all work will be performed by homeo "4,00, E 11 E • Contractor: Workers' Comp documentation must © ' ` ubm el lvil9th s plication Contact Name(s): 0_- r vkJ\ -s TOWN or QUCCNSBURY Contractor Trade: °vim BUILDING&CODES Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: _( Email: **List all additional contractors on the back of this form Contact Person for Building & Code Compliance: -1�?\ice fi Cell Phone: ( ) Land Line: (� ) Email: Demolition Application Revised February 2019 DEMOLITION INFORMATION: 1. Where will demolition material be disposed? I'kkooF fA- . % 'C7 ‘-\t,tAt_Th ige -kMQ1 2. Type of structure to be demolished: b C tR7 i5 A IOc. -t NDG a. ResidenceT \-N7ty \c 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 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: eNvc- SIGNATURE: G' i DATE: 5%//9 Demolition Application Revised February 2019