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application
Office Use Only DEMOLITION APPLICATION Permit#: �� • 0i 1 - 221 Permit Fee:$ ` ✓© Invoice:#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Demolition Location: '3 1 0 f o t Ind M. Tax Map ID#: `Z Z- 2— **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS** CONTACT INFORMATION: • Applicant: Name(s): _7iq F Cnn 5 v uc- i oeN L(.0 e-:s Mailing Address, C/S/Z: 1 n 6el Rc�l,we. A It Cell Phone: * ) 6-06 -43q-7 Land Line: Sr't Email: ;0,>0e-9 anF C,0r.s�ruc-1-4o.1 'Die514✓1 . w1 • Primary Owner(s): Name(s): i4ormva^ 2. Mailing Address, C/S/Z: 31 ©1 W sse i 61�j Poini Rd Qoeap ;b i h1 Y Cell Phone:_( 3.3ef ) 757o - as q b 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): ;3-u jj de54-Grj L(L� Contractor Trade: G�,ne� r e,^j,-o.c--o'r Mailing Address, C/S/Z: tobq Po.("r Cell Phone:_( !�-16 )_ T 9 j?- 1F3 q-7 Land Line: _( ) Email: 6 Q5Qe-Q - cI s o JP m *List al additional contractors on the back of this form Contact Person for Building & Code Compliance: l r nD __ � ( � Cell Phone: _( ) Land Line: ( {{ 11 Email: _ K k t DEMOLITION INFORMATION: 1. Where will demolition material be disposed? WA5+e IM6AQAemen4 4oL4,pan:/ 4o t.,fe . 2. Type of structure to be demolished: a. Residence "%j5e-) (66e4 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-a e. Public Water f. Well-Water Pump c (4V15L0"w g. Public Sewer_ 1�1 Cdisczvq-c-W h. Other i. None Y 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: .70-5,)e ►;-(o eS SIGNATURE: DATE: IZ ly / -E