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Office Use Only IDD - Oj2- 2_02Z
Permit#: G'
DEMOLITION APPLICATION
Permit Fee:$
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742 Bay Road, Queensbury, NY 12804 ,y,ti d
P: 518-761-8256 www.queensbury.net LJIL� L "2UL0
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Demolition Location: �j `� y j r i�`Z j �� Tax Map ID#: 2 S a-- `7
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): )40-11 i �.— ) I (,; 't--s
Mailing Address, C/S/Z: �� Y �_�-{1 __ Lc�. I LL_ �, ,�f /,9—S [i/
Cell Phone: ( ( y ) -x-.) i) Land Line: ( )79---
Email: M i h ei; (,),--.2 giy704 i_ r (.6 ;-p7
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: (f; ( > f C '�__ ( {7:L 5` /=.�-
Cell Phone: _( ) 6;sc; 3 7 Land Line: _(
Email: ;,i i '('t S r' /_( 1 tJ VII /
❑ Check if all work will be performed by property owner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): r}.--z {') rY) f3 q)
Contractor Trade: t 4- ;1 0-1—1
Mailing Address, C/S/Z: 5-y- N C'V 7Go--Lb.; !1-7 /'3
Cell Phone: \.'+I 3 Cr, ( ( Land Line:
Email:
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: (4i(_.--4 . 11 Srj
Cell Phone: ( -I ) (��;( , ` Land Line: _( ?-
Email: ; I-��� �Li!} (��r� `' 1 M ff-i
Demolition Application Revised January 2020
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DEMOLITION INFORMATION:
1. Where will demolition material be disposed?
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
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
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: / l ' o- Q fQ .1-e)
SIGNATURE: 'C DATE: a�
Demolition Application Revised February 2019