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application Office Use Only i7.-may. Permit#: LAG—�1(J— f) 5 ' 2 Q I DEMOLITION APPLICATION Permit Fee:$ ISO Town of(Zuccnsbury `� Invoice:#: 742 Bay Road, Queensbury, NY 12804 P: 518-761-8256 www.queensbury.net Demolition Location: q3 !1 ` n JI- Tax Map ID #: 30G► - lc - )--'S 2_ **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS** CONTACT INFORMATION: • Applicant: Al,1�t, I _ n- ` /Name(s): .c-•� - , h /" , �{' Mailing Address, C/S/Z`. S Lieslntd i , G�As /U l' / Zj.v J Cell Phone: ( 5!� ) 1)10-1 y/ 9 Land " ) Email:\jC,,k f n.t_, f .{,� at r- © o,,,,,, •Orin • Primary Owner(s): • Name(s): f e I,c r c� Pi\�.Lk .. l E fi-,- 'fl - - Mailing Address, C/S/Z: -�� �� c^,� �' �� IV � Cell Phone: _( /$ ) LP S Z3 7 .S Land Line: _( + 211öI Email: TOWN OF 0U BUlCD1N^ E`NSDUc, ❑ Check if all work will be performed by homeowner only _r`ODES''Y • Contractor: Workers' Comp documentation must be submitted with this application Contact Name(s): \3D 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 Building & Code Compliance: .1\-0?\ ( ,r\-- Cell Phone: ( ) Land Lie: ( ) Email: Demolition Application Revised February 2019 DEMOLITION INFORMATION: / / 1. Where will demolition material be disposed? 71t)v b��Zd t51 �1 ,[CJ)r 2. Type of structure to be demolished: a. Residence b. Garage c. Business d. Storage Building 3. What type of utilities are connected to the structure: a. Gas V b. Fuel Oil c. Propane d. Electric e. Public Water V 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: C/ ��—� 66LF-Cklk SIGNATURE: DATE: l Demolition Application Revised February 2019