application Office Use Only
ill.,1110114 ) DEMOLITION APPLICATION Permit#: DC1Q ~ blv�1 -ZQ2�
® Permit Fee:$ 150
Town of Quccnsbury
Invoice:#:
742 Bay Road, Queensbury, NY 12804
P:518-761-8256 www.queensbury.net jusi- %-Vo 0k1
Demolition Location: J ax Map ID#:
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION jussi-pNs*
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CONTACT INFORMATION: • NOV 0 4 2020 II J
I :-
• Applicant: r, TOWN OF G-UEEI!Sl3[RY
Name(s): Ea/ice- keARcii BUILD!BULDING a CODES
Mailing Address, C/S/Z: 455 l.v?e2NL- P-01 Que-eNzury 710
Cell Phone: ( ) Land Line: ( s/S ) 7`t. -6/2
Email: ke_nntol j 455 9 mA I1. ,Co f�
• Primary Owner(s):
Name(s): EwJ Cam- n-ect j
Mailing Address, C/S/Z: `I 55 LUZef, is /2 g vdteno Bari N V/ !7 O >f
Cell Phone: _( ) Land Line: _( 5(g )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): 111 irot,'d°s-tc Irdu& fi e4
Contractor Trade: c(\VA 691‘1/4-aALeo 2
Mailing Address, C/S/Z: 9 Ptt( L►J CokUJ1 I4 N Y
Cell Phone: _( ) Land Line: _( S1 ) G 5,I - 7(460
Email: R4IroOa t-K-I NdUSi7L'es a emu.cv M
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: 1 01-1(7 "k'
Cell Phone: _( ) Land Line: _(
Email:
Demolition Application Revised February 2019
DEMOLITION INFORMATION: (7 FJ ko-
PAqs SAIVg9° 4vffN4&)rj, Ih 12-soi
1. Where will demolition material be disposed?
2. Type of structure to be demolished:
a. Residence -ABeve c rza1\Jd POD L -p 4f\hau) qP-bJNo
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 Q/
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: CLJ,V
SIGNATURE: DATE: iII2.020
Demolition Application Revised February 2019