application Office Use Only
f DEMOLITION APPLICATION Permit#: ��rn v !U 7 S7—ZoZC�
.. � rFD
� r� Permit Fee:
Q Town of ueensbu rInvoice:#: Z742 Bay Road,Queensbury, NY 12804EC Q 3 202�
P:518-761-8256 www.4ueensbury.net
TOWN OF OI_fEEN1,c 8 1!R(
bJ1E_C?€6`SO v
Demolition Location: 53 Assembly Point Road Tax Map ID#: 239.12-2-16
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): William&Kathleen Bosy
Mailing Address, C/S/Z: P.O. Box 1 Lake George County of Warren, New York 12845
Cell Phone: 518 )321-7746 Land Line: 518 )668-9002
Email:llib30l@aol.com
• Primary Owner(s):
Name(s): William &Kathleen Bosy
Mailing Address, C/S/Z: P.O. Box 1 Lake George County of Warren, New York 12845
Cell Phone:_(518 )321-7746 Land Line: _(518 )668-9002
Email:Ilib301@aol.com
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application ,z
Contact Name(s):—)e46 ,>O
Contractor Trade: s — -�
Mailing Address, C/S/Z: /5 &
Cell Phone:_( -) ���—f f f Land Line: _( /�� ) 79oZ 9Q 4-&
Email: c�taIL&� C a//SZogye7'4 C=xc?A UA7-WUrg nC?g,v
I "List all additional contractors on the back of this form
Contact Person for Building & Code Compliance:
Cell Phone: _( ) Land Line: _( )
Email:
Demolition Application Revised February
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? �e� lU���� Rik V y&R-05/9
2. Type of structure to be demolished:
a.,. Residence X
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 X
e. Public Water
f. Well-Water Pump
g. Public Sewer
h. Other
i. None
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 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:
SIGNATURE: d �` a� % DATE: 14A,
Demolition Application Revised February 2019