applicationOffice Use Only
DEMOLITION APPLICATION_|Permit #__D®o—n0S7-2020
E |Permittee:1S0.002|invoice:__2S7S”
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Demolition Location:Xl Cloverdale XL Cherdblerax Map w #226.)2-1-3
**AN ASBESTOS REPORT IS REQUIRED WITH ALLDEMOLITIONAPPLICATIONSUBMISSIONS**
CONTACT INFORMATION:
°licant:
Name(s):sae,bd hots -Wd Willams Const Tou.Mailing Address,C/S/2:PO Bax 241,Cleveclale NV iz629CellPhone:_(574 _)/-2140 landline:(S28 _)ast -2577Email:_welwmse ons?Ohetme/.20/1
e Primary Owner(s):
Name(s):Chris ¢Mary Lattso
Mailing Address,C/S/2:/04!Sulum KL.ZLontaster_,PA LeCellPhone:(7/7_)_20/-721 land Line:_(_378 )_Cosh -9429Email:_chinsdra le &-anail.Aan
7
O Check if all work will be performed by property owner only
¢Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s):Lavec AtU ams —W)Willams Zc Fre,Contractor Trade:__General (onhyacdo
Mailing Address,C/s/2:PO {x 2d/ Cleverdale WV 12320CellPhone:_(5/9 _)_79/-ag 4d land Line:(5/8 )656-3577Email:ems Const@hotmal).ton**List all additional contractors on the back of this form
Contact Person for Building &Code Compliance:Mane MMi entsCellPhone:_(378 _)Lupig land Liné:(57 )686-3579Email:welzy m-4 pilmarl,com,
Demolition Application
Revised January 2020
¢Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s):Wayne 1d
Contractor Trade:_(Gene/gl ConHeetor
Mailing Address,c/s/2:VD Adx 24]Cleverdak WY Jj¢2 0
Cell Phone:(5/2 )79/-.2/land line:“(57%)L5@-$577Email_WdiInGcanst D hy To.T Coy
¢Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s):CLS Crenda//
Contractor Trade:¥CavA Tor
Malling Address,(s/2:(3 4 dd Mee KUL 1 Koel LN?Gearqe NY ILACellPhone:(3/8 _)770-97 land Line:(S57F)793 OBBEmail:CA/,Scaadellgs Girt 1a
°Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s):
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone:_()Land Line:_()
Email:
¢Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s):
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone:_()Land Line:_()
Email:
*Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s):
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone:_()Land Line:_()Email:
*Contractor:Workers’Comp documentation must be submitted with this applicationContactName(s):
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone:_()Land Line:_()Email:
Demolition Application
Revised January 2020
DEMOLITION INFORMATIO!
1.Where will demolition material be disposed?fort Aa Teneder Soh)2.2.Type of structure to be demolished:
a.Residence
b.Garage _X_.Businessd.Storage Building3.What type of utilities are connected to the structure:Gas__
Fuel OilPropane
Electric_y_
Public Water
Well-Water Pump ___Public Sewer ___Other
i.None
4,Have ALL uti
FRB
ae
Te
ities been disconnected?Yes_X No
ADDITIONAL INFORMATION:
1.Two inspections may be required:an inspection to determine that utilities are disconnected,ifnecessary,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.
|acknowledge that no structure(s)will be removed from the parcel until the demolition application hasbeenreviewedandapprovedbytheTownofQueensburyBuilding&Code Enforcement and Zoning Departments and apermithasbeenissued.
'have read and agree to the above:
PRINT NAME:lh Me Cae
signarure:_//fe Man DATE:B,i fpord
Demolition Application
Revised January 2020