DEMO-0874-2021 T, 1
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Office Use Only
a- F)
DEMOLITION APPLICATION Permit#Permit Fee:
Torn ofQuecnsbury Invoice#:
742 Bay Road,Queensbury,NY 12804 -
P:518-761-8256 www.pueensbu�.net Flood Zone? Y Reviewe
Demolition Location: Tag Map ID
**AN ASBESTOS REPORT IS REQUIRED WITH ALIT.:-
- DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? P�r'�N� Pa/hj o� �/ eb�•�►�'� _
2. Type of structure to be demolished: ((
a. Residence d.rStorage Building g/eE: O
g V E
b. Garage e.Other: A.ro c. Business❑ 2021
3. What type of utilities are connected to the structure:
a. Gas❑ f.Well-Water Pump❑ UEENSBURYb. Fuel oil❑ g. Public Sewer❑ G?�CODES
c. Propane❑ h:Other
d. Electric❑ I. None
e. Public Water❑
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-thee
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 agrroo the ove:
PRINT NAME:
SIGNATUR DATE: Z
Demolition Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z: low
Cell Phone: Land Line:
Email:
• Primary Owner(s):
Name(s): 54,a►� _u dG.i.� `- - - -- : --
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
RClieck if all work will be performed by property owner only
• Contractor: (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z: =
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application'! ,
77110,i 0, /Wc.. �a c�•i! �� �/ct -fit �5 o Gex�/�.e .
4c, ctio.l�
Contact Person for any questions regarding this project: -7t446-61le 7v •�k4m0p,
Cell Phone: Land Line: .014-- ez > CL
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Demolition Application Revised December2020-- ---