application Office Use Only u�/ /
t/API) ` r (,� �1/l r' n`_ Permit#: Ip �0 I'1 i `-zo( 9
DEMdL IICATI'ON'
jj0. (>U
Permit Fee: $
Town of(Zuccnsbury .1 JUN 27 2019
-I Invoice:#: 1 3 7
742 Bay Road, Queensbury, NY 12804i TD��—N'OF QUENSBLiRY
P: 518-761-8256 www.queensbury.net Rt nin+n &CODES
Demolition Location: 34/7 Avie.lio.-) l�o,.fl Tax Map ID #: 3o/0g-/33
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): 54-,0l,e., L%(...cf,r•d;
Mailing Address, C/S/Z: 29,7 Qo,}c 9 - /34)100, sue, ,v/ /7,0a0
Cell Phone: (SW ) ? -lolo'Y Land Line: (S/7 )S-if/-izo, ex.). Y2Y7
Email: S/;rc.,c._I'cd-, e 5I-eww.4ssl.o?c . cow,
• Primary Owner(s):
Name(s): S}etA/G,r.ls Shoes Cote...+;c -,
Mailing Address, C/S/Z: 2902 )<'o,,}c 9 - L3I/S1on SDa Aft /2o .o
Cell Phone: _(5iK ) 72'V-CP/PYy Land Line: ( sit' ) Sri-izo) eicf. 12 O
Email:SlicL',ar,i; e s--ewo r4c5 lops. Cow,
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): S}ewG,,,4s S1, ps Corenr.io„
Contractor Trade:
Mailing Address, C/S/Z: 29o) Ra,A}c g — 40.0or, Sec. 4/Y /2 o 2 D
Cell Phone: _(./ ? ) 77'1-6( i'i Land Line: _( s/K ) -CO- t o/ eXf. tizY7
Email:S IiCc.i a rc tS-le.),,r-lssj,pc . c.,,,
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance:.S.-k ite- Li r4.rd i
Cell Phone: The ) 27 y-(pto y i Land Line: _(Si ) ..Wi-/zol 04. `/.z 9?
Emai l:,s/;Ct i ArA Slr ..i S1,Qpc. c-o,i,
Demolition Application Revised February 2019
t
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? 6 ...sev or-4 , 4/fri
2. Type of structure to be demolished:
a. Residence
b. Garage -/
c. Business X
d. Storage Building
3. What type of utilities are connected to the structure:
a. Gas
b. Fuel Oil
c. Propane
d. Electric A/
e. Public Water K'
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.
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: e i r
SIGNATURE: DATE: 6/V./hi
Demolition Application Revised February 2019