application h
Office Use Only
it#: �J(� o
l DEMOLITION APPLICATION Perm _
(�� �� Permit Fee:$ ! J
Town of(Zccnsbury D EC E O W E a �
Invoice:#: Z5 3 6
742 Bay Road,Queensbury, NY 12804 MAY 2023
P: 518-761-8256 www. ueensbur .ne I�
TOWN OF QUEENS8Ll.'v
BUILDING&COT') S
Demolition Location: n rjT—e— Tax Map ID#: 9,
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): rdIL-6 9T. Cuo f--�
Mailing Address, C/S/Z: tj L P—
Cell Phone: ) 6�E� s aD Lam— Land Line: �v )
Email: M i o
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• Primary Owner(s):
Name(s): ,.
Mailing Address, C/S/Z:
Cell Phone:_( sa k ) 9 Land Line:Email: wipe
❑ Check if all work will be performed by property owner only ,
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): _ C , ..-z, tt�S I'n t P 0 M ELL)
Contractor Trade: 4
Mailing Address, C/S/Z: p &, LZ e, /%--
Cell Phone: _( NS-I,P ) G, ( D 'fg Land Line: _( )
Email:
"List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: 04i l_
Cell Phone: _( �I� ) �5� Land Line: _(
Email: I• a- ;arc i L.1
Demolition Application Revised January 2020
DEMOLITION INFORMATION:
1disposed? L�9t YVIY�°�r? Cn�
. Where will demolition material be
J
2. Type of structure to be demolished:
a. Residence
b. Garage
c. Business
d. Storage Building
3. What type of u ilities are connected to the structure:
a. Gas
b. Fuel I
c. Propane
d. Electric
e. Public WFeer
f. Well-Water Pump
g. Public Sewer
h. Other 2�Q <ct-( '
L 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.
have read and agree to the above:
C
PRINT NAME:
c
SIGNATURE: DATE:
Demolition Application Revised January 2020