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application
Office Use Only DEMOLITION APPLICATION rermte DESO“ CiNo= 202) permitree:$_!7° Ton of Qucensbu "invoices:24," 742 Bay Road,Queensbury,NY 12804 P:§18-761-8256 www.queensbury.net Demolition Location:2 He Po Fy taxMapwe:287 u-l-{1 **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS** CONTACT INFORMATION: ©Applicant: Name(s):At Lerpero Mailing Address,C/S/Z:_Leiwesrert!DDR Coser,Mae,“7 /2OGc~ Cell Phone:_(Sigz )Bo%$3417 —Land Line:) Email__AdAny @ BCRAME 77).Cony ©Primary Owner(s): Name(s):Ansar +RED Coontz o>Mailing Address,C/S/Z:__anu AS AresCellPhone:_(Land Line:_(). Email: AXCheck if all work will be performed by homeowner only ©Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s): Contractor Trade:[Ee = Mailing Address,C/S/Z:Uy ST ] Cell Phone:_()Land Line:(777)ya.UT Email:pe ANT 0 TT **List all additional contractors on the back of this form (0, Contact Person for Building &Code Compliance: Cell Phone:(___)Land Email: Demolition Application Revised February 2028 DEMOLITION INFORMATION: 1.Where will demolition material be disposed?__eons pe72fe- 2.Type of structure to be demolished: a.Residence _S~ b.Garage cc.Business d._Storage Building 3.What type of utilities are connected to the structure: a.Gas Fuel OilPropane___Electric Public Water Well-Water Pump __Public Sewer ___Other ee aoe re i,None dc 4.Have ALL utilities been disconnected?Yes _X 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 subr ‘ed with this application. Declaration:|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. |have read and agree to the above: PRINT NAME:Sy sounne.££pate:_S/ifroze Revised February 2019,Demolition Application