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application Office Use Only DEMOLITION APPLICATION Permit#: �C-1�0' 6. Permit Fee:$ IF� :1) -� Town of Quccnsbury sa, Invoice:#: 3oe)2_. 742 Bay Road,Queensbury, NY 12804 P: 518-761-8256 www.ciueensburv.net Demolition Location: 48 Louise Lane Tax Map ID #: 289.6-1-17.5 *AN ASBESTOS REPORT IS .REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS** DIECEOWE CONTACT INFORMATION: OCT 22 2020 • Applicant: Name(s): Mary Sicard TOWN OF QUEENSBURY Mailing Address, C/S/Z: 11 George St, Lake George; NY 12845 BUILDING& CODES Cell Phone: (518) 744-1888 . Land Line: (518) 792-5963 Email: msicard@glensfallshosp.org • 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): Charles Friedman Excavating Contractor Trade: Excavator Mailing Address, C/S/Z: .54 North St, Hudson Falls, NY 12839 Cell Phone: (518)361-1748 Land Line: (518)747-9371 Email: cfriedmanexeavating.com **List all additional contractors on the next page Contact Person for Building&Code Compliance: Charles Friedman Cell Phone: (518)361-1748 Land Line: (518)747-9371 Email:cfriedmanexcavating.com DEMOLITION INFORMATION: 1. Where will demolition material be disposed?Waste Management, Gansevoort NY Demolition Application Revised January 2019 2. Type of structure to be demolished (check all that apply): a. -Residence El b. Garage ❑ c. Business ❑ d. Storage Building ❑ I e. Other ❑ (describe: ) 3. What type of utilities are connected to the structure (check all that apply): a. Gas ❑ b. Fuel Oil ❑ c. Propane 0 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: Mary Sicard SIGNATURE: 7,1 5Z C/' DATE: Demolition Application Revised January 2019