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DEMO-0846-2021 Office Use Only DEMOLITION APPLICATION Permit#:.De`10 ' Ob2\,o - 2021 11 Permit Fee:$ t 5l Town of Queensbury Invoice#: 742 Bay Road,Queensbury,NY 12804 n„ P:518-761-8256 www.Queensbury.net Flood Zone? Y Reviewed By: � Z 1�Q,1Sor��• - Demolition Location: Tax Map ID#:5 q 3"o q-<mj, I't� —73 **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION-SUBMISSIONS** DEMOLITION INFORMATION: to 0 , ,�j 1. Where will demolition material be disposed? n)6 ale, �w�� o�-� ar ` 2. Type of structure to be demolished: a. Residence d.Storage Building❑ cb. Garage 0 Other: . Busin P b 61 FH ECEOVED 3. What type of utilities are connected to the structure: NOV Z 9 2021 a. Gas❑ f. Well-Water Pump ❑ b. Fuel Oil ❑. g. Public Sewer❑ TOWN OF QUEENSBURY c. Propane ❑ h. Other I BUILDING&CODES d. Electric ❑ i. None e. Public Water❑ r 4. Have ALL utilities (water, electric, etc.) 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: �1 PRINT NAME: MADE .AMA LS5e_ l SIGNATURE. DATE: /I' Z6 --Z02/ Demolition Application Revised December 2020 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE-INCLUDE AN EMAIL • Applicant: - �.�� �— 0 2 l S,S jl Name(s): ILI F1 cZf� Ko(R k t s5E � Mailing Address, C/S/Z: . / R A,I1_( 0 ad Cell Phone: Land Line~ C, `ORC tUX Email: g)© [= • Primary Owner(s): N O1 S Z: �l ��L �0� Mailing Address �� � 4 C/ /Cell Phone: Land Line:-- �'KE 6 _EEO 6� Email:100 C&V/— —1 99 _—�( 3 ❑Check if all work will be performed by property owner only • Contractor: (List all additional contractors on the back of this.form) Contact Name(s): zS; �� l p� lLvvL Contractor Trade: � Mailing Address, C/S/ C� �,G I . Cell Phone: Land Line: . ��� (� Email: ��' V-)C,\j "Workers' Comp documeQon must.be submitted with this application" Contact Person for any questions regarding this project: Cell Phone: Land Line: Email: Demolition Application Revised December 2020 o. zp (� CJ m �z- Q� RC o j• LII �a c as - =U _ V 4 1 N U or. cq 288.16-1-73 DEMO-0846-2021 Morrissey, Marie 12 Nelson Rd Filling in in-ground pool