application C,
offic se Only
DEMOLITION APPLICATION Permit#: zz�
Permit Fee:$
7im,11 of. ucells)[IT'l
Invoice:#:
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.queensbu�r .net
Demolition Location: &U koell Tax Map ID#: 3c)"2- , Z-
**AN ASBESTOS REPORT IS REQUIRED WITH ALE_r
DEMOLITION APPLICATION SUVI�1"i 18S_ TONS';-'.-
,j -
CONTACT INFORMATION: i I HC 29 2 11"A
T.
0 Applicant:
Name(s): J36E)AZe rCrn I-AV-1
Mailing Address—, C/S/Z: �_� &_
Cell Phone:
65toxw Land Line:
Email:
• Primary Owner(s): II
Name(s):
(A )n
Mailing Address, C/S/Z: f z 3 TZIS
Cell Phone: Land Line: )'7
Email:
El Check if all work will be performed by homeowner only
• Contractor: Workers' Comp document t" n must be submitted with this application
Contact Name(s): 77-71l 0-ri
Contractor Trade: 0�
Mailing Address, C/S/Z: j1JL/ 13113e;f
Cell Phone: Land Line:
"List all additional contractors on'lNe b ck of this form
Contact Person for Building & Code Compliance: I'Virk-
Cell Phone:
tj, 4 Land Line:
Email:
Demolition Application Revised February 2019
4
DEMOLITION INFORMATION:
1. Where will demolition material be disposed?/l
2. Type of structure to be demolished:
a. Residence
b. Garage
c. Business:/—`—, —
d. Storage Building
3. What type of utilities are connected to the structure:
a. Gas 7`=—
b. Fuel Oil
c. Propane
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:IL L111 .S ,bj, In
SIGNATUR : DATE: ,7- 2p
Demolition Application Revised February 2019