application ff Office Use Only
DEMOLITION APPLICATION Permit#: `I�IN4A-010 r--202°
Town of Queensb ry
Permit Fee:$ I5Q
742 Bay Road,Queensbu ry, NY 12804 Invoice:#:
P:518-761-8256 .www.q u e e n s b u ry.n e t
Demolition Location: 115.Vandusen Rd,Queensbury, 12804 Tax Map ID#:308.11-1-23
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CIECONTACT INFORMATION:
riiuii51
OCT 2 2 2020 1 jj
• Applicant: I
Name(s): Maureen Conroy TOWN OF OUEEhlSBURY
Mailing Address,.C/S/Z: 36 Farmview Lane, Waterford, NY 12188 BUILDING CODES
Cell Phone:_(518) 708-7440 Land Line: _( )
Email: maureen@forbairdevelopment.com
• Primary Owner(s):
Name(s): Same as Above
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: ( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): Foothills Property Management, LLC
Contractor Trade: General Contractor
Mailing Address, C/S/Z: 24 Briwood Circle, Queensbury, NY 12804
Cell Phone: (518) 812-4981 Land Line: _( )_
Email:foothillspropertymngmt@gmail.com
**List all additional contractors on the next page
Contact Person for Building&Code Compliance: Maureen Conroy
Cell Phone: (518)708-7440 Land Line:_( )
Email: maureen@forbairdevelopment.com
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? Dumpster
Demolition Application Revised January 2019
•
2. Type of structure to be demolished (check all that apply):
a. Residence �"_!
b. Garage /Z1
c. Business 0
d. Storage Building ❑
e. Other 0 (describe: )
3. What type of utilities are connected to the structure.(check all that apply):
a. Gas ❑
b. Fuel Oil ❑
c. Propane.❑
d. Electric
e. Public Water E
f. Well-Water Pump 0
g. Public Sewer 0
h. Other
i. NoneM
4.. Have ALL utilities been disconnected? Yes No 0
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: irUblltre5e41\ COVIArny#
SIGNATURE: DATE: P a,0 0201 j
G
Demolition Application
Revised January 2019