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DEMO-0669-2021 Office Use Only W0_ueensburyv DEMOLITION APPLICATION Permit#: �� © 0Co.Permit Fee:$To Invoice#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensburv.net Flood Zone? Y N Reviewed By: Demolition Location: I Tax.Map ID#: 239.12-2-37 33 Holly Lane,Lake George,Ny 12845 **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS** DEMOLITION INFORMATION: 1. Where will demolition material be disposed? Fort Ann Commercial 2. Type of structure to be demolished: a. Residence d.Storage Building❑ D �n E b. Garage❑ e. Other: Seasonal Camp V c. Business ❑ 3. What type of utilities are connected to the structure: SEP 0 8 2021 a. Gas❑ f.Well-Water Pump® TOWN OF QUEENSBURY b. Fuel Oil ❑ g. Public Sewer❑ BUILDING Q CODFS 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 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: Brian T. Hogan / SIGNATURE: — C DATE: 09/08/2021 Demolition Application Revised December 2020 } f s CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): BRIAN HOGAN M a i I i ng Ad d ress, C/S/Z: 33 Holly Lane Cell Phone:424-7872 Land Line: 518-656-3504 Email: Bdan.Hogan34@gmail.com • Primary Owner(s): Name(s): BRIAN HOGAN/MEREDITH HOGAN Mailing Address, C/S/Z: 34 Holly Ln.,Lake George,NY 12845 Cell Phone 424-7672 Land Line:656-3504 Email: I3dan.Hogan34@gmail.com ❑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): Ellsworth and Son Excavating Inc. Contractor Trade: Excavating/Demolition Mailing Address, C/S/Z: 10302 State Rt.149,Fort Ann,NY 12827 Cell Phone:361-1993 Land Line:792-9246 Email: Digging@ellsworthexcavting.com "Workers' Comp documentation must be submitted with this application" Contact Person for any questions regarding this project-,�Zcm-,,{� Cell Phone:424-7872 Land Line:656-3504 Email: Bdan.Hogan34@gmail.com Demolition Application Revised December 2020 � a FILE COPY , Asbestos Survey Brian Hogan BUUILDING DEPARTMENT 33 Holly Ln Based on our limited examination,compliance with our comments shall not be construed as indicating the plans and specifications are in Assembly Point, NY full compliance with the Building Codes of New York State. Inspection date: 8/27/2021 Tom Callahan/TC Inspections D C E5 0 E 1 Knolls Dr SEP 0 8 2021 Oueensbury,NY 12804 Inspector# 17-42926/Contractor# 109425 TOWN O QUEENSBURY G& CODES cell# 518-832-9750 TOWN OF QUEENSBURY 239.12-2-37 DEMO-0669-2021 BUILDING & CODES DEPT. Hogan, Brian Reviewed By: A^ -S 33 Holly Ln ,� Demolition of SFD Date: Summary of Inspection At the request of Brian Hogan an asbestos survey was performed at 33 Holly Ln Assembly Point, NY . Scope of the Inspection/Survey is to determine if the house contains any asbestos prior to demolition . Suspected Asbestos containing materials were removed and sent out for sampling. The following samples were removed and sent out for testing. Homogeneous area 1( nonfriable) asphalt shingles (none detected) Homogeneous area 2 (nonfriable) Bathroom vinyl floor (none detected) Homogeneous area 3 (nonfriable) Kitchen vinyl floor (none detected) Homogeneous area 4 (nonfriable) Wallpaper (none detected) Homogeneous area 5 (friable) drywall (none detected) Things to note THIS REPORT SHOULD BE MADE AVAILABLE TO ANY NEIGHBORS. THIS REPORT SHOULD ALSO BE READILY AVAILABLE AT THE LOCATION OF THE DEMOLITION/RENOVATION FOR ANY TRADES PEOPLE ENGAGED TO CARRY OUT REPAIRS OR DEMOLITION OF THE PROPERTY. Conclusion No Materials were identified as containing more than 1% asbestos material. Therefore no asbestos abatement is required. A copy of this report should be kept at the work site. A copy of the sample analysis is attached to this report 1; 'c s O,. New`fdrk State Repprtrtigntgq# Y" I, Division oShtetynd Health. .r CUM? !<-�s• fie"=,. =License and Ck"#ii s � ; State C__pus"$hill g 12' fi at <z<' s' ,��# Albany,tJY 122^�•4/0 " 1s STOS HANDLING LICEPfSr; _ � ,q M.Caitahap ba TC inspectibps;':.:; '";FILE NUMBER. 'Y-109425 / '• A ':y� LICENSE NUMBER's9425 e'31 -nolWdrive LICENSE CLASS: RESTRIC'iE z ;DATE OF ISSUE: 01/0812021 EXPIRATI,O DATE: 01Y81120�2 tQ eehsbury.Tsl 12 iA ` Ae � 3� { .�''� r"�f`Y.'.� •`�F i7ir'z`�"7 �z�'�� .. .r`S, � S`y �� ��� ' is � .. .f:'i may.' !•, r� ' � tf d b lyf_AgthorizeA Dresentative=. m hoaQalfb&i'. ;;`< y_. •' ": } �• � , 'r .•• zr' •�= i 1^��t t't� 9 js.�=3r,&,..'.� „_:'.,-Al .,i,•,..�f �;� �%n•„ s� 1is fip~egj bias 1',n issued in ac are;tvith{; llptical,slo pi siiision "of Atiicli :(1"Uf the���J}gtxor Law ofNew ,xyrk'g6f,atYt3 01� No Ngjy�Yol V4 Codes,Rules 1,Z,tegulatiiie�s t"12{1YCRR Part'S6j'Elie it5�ect tit susp usion or rcvocattbn for u(1) sous,olati o laic,federal t l cal laws 1ctt.rCg�jrd fp ihic c9nducYUf ur tfestos ptoj i11�,Ut(2)dcmOtSs ra d iat k„o r o>f ibit ty on thi conduct ot'any 31b}in�ol4i sips oraibes dsffi�te�la[.b3' � �. � y rp.. . v- r §3 �€y x,. r5d 6 u!' .".°,i£'! " :,✓°. -'. i '. .-....t p, 7'' y 6 Thi�liccdse ii;,v ri onl for'tyie c�otitractor natneti'tiffnve ane ( i liccitse iih a}ilm"tocopy must s pr6m n�tttty disptayc(at, e asbesto3s proje�g0w,fX it "Ol s.liccpse ven#ies thaaall',persons employ dla�Y the ticeii8ee on ari'dsb'cst4s=proje u�•J1rw`Yo[k State gaye'een., u'ed ana bcstos Certificate:appfopKt fi ri0"e ty``p.4i4cit•they perform,by tl e.3�Tew Yo�@ DeparttsrtoVp for.°> f _.... \ -00 add � � J teen M.Franko, Director SH 432(8112) -f% v, � a�a for the Commissioner of Labor ;u^STl4t`tr tJF,� I 1 PPART fP+1T�fib} ,05�£STC3SGt:ttT7f� t1t3R �� - ' f ','3,•,1,�-ty'I.��it�AJ;t1d� 1,6 �k.`�e P•'+ 1, ..•.E=.e.x�.:�>1-..-_....,fR;., 'R,4•;.w�.,�<,•....,. t>�t�,t��{ nr'{��� E EMSLOrder 08211744A MSLAnalytical, Inc. 528 Mineola Avenue Carle Place,NY 11614 Customer ID: TCNS29 Tel/Fax:(516)997-7251 f(516)097-7528 Customer PO: m hiP1fVMw.EMSL.0m4 cadaplacgnb@omsi.com Project ID: Attention: Tom Callahan Phone: (518)832-9750 TO Inspections Fax- 1 Knolls Drive Received Date: 08/3012021 1:28 PM Wueensoury,ivy -izao4 ,Arraryata Date, ODJOI12021 Collected Date: 08/27/2021 Pro ect: 33.Holly l-n, Test Report:Asbestos Analysis of Bulk Material Analyzed Non-Asbestos Teat bate Color Fibrous Non-Fibrous Asbestos SomplaID HA1-RS1 Description Roar-Shingles 002117444.OMI Homogeneity Hsterogeneous PLM NYS 198.1 Friabfo Not Analyzed PLM NYS 190.6 VCM Not Analyzed PLM NYS 198.6 NOB 09101l2021 Slaw Blue 320%Glass 98.90%Other inconclusivo:Norio Detected TEM NVS 198.4 NOB 09101/2021 Black/Blue 100.00%Other Notts Detected SamplolD HA1-RS2 Description Roar-Shingles 002117444-0002 Homogeneity Heterogeneous PLM NYS 198A Friable NotAnalyzod PLM NYS 198.6 VCM Not Analynd PLM NYS 19815 NOS 09/01/2021 Btackf Blue 0.00%Glass 100.00%Other inconclusive:None Detected TEM NYS 199A NOB 0910IJ2021 Slackr Blue 100.00%Other None Detected SompletD, HA2•SVFl Description Bathroom-Unyi Floor 062117444-0003 Homogeneity Heterogeneous PLM NYS 108.1 Friable Not Analyzed PLM NYS 198.E VCM Not Analyzed PLM NYS 198,E NOB 09/01/2021 White/Beige <1.00%Glass 100.00%Other Inconclusive:Nona Detected TEM NYS 198.4 NOS 09101f2021 Whites Beige 100.00%Other Nano Detected Sample iD HA2-SVF2 Description Bathroom-Vinyl Floor 082r17444.00aq Homogeneity Heterogeneous PLM NYS 198.1 Friable No!Analysed PLM NY8198.6 VCM Not Analyzed PLM NYS 198A NOB 0910112021 White/Beige 41.00%Glass 100.00%Other inconclusive:None Detected TEM NYS 193.4 NOB 09/0112021 Whital Beige 100.00%Other None Detected Sample10 HA9-KVF1 Doscr'lpdon Kitchen-Vinyl Floor 062117444-=5 Homogeneity- HoterogeneouslHOmageneous PLM NYS 198,1 Friable Not Analyzed PLM NYS 198.8 VCM Not Analyzed PUN NYS 198.6 NOB 09/0112021 White/Beige 100.00%Other Inconclusive:Nona Detected TEM NYS 198.41408 091OM621 White/Beige 100.00%Other None Dotocted initial report from:OW021202109:01:01 ASti_199z 999 O0a7 Printed 9/2l2021 9:01:03AM Pago 1 at 3 S EMSLAnalytical, Inc. BMSLOrdor oszll�aaa 528 Unsafe Avenue Cade Pike,NY 11514 Customer ID: TCNS29 TONFaz:(516)997.7251/(516)997.7626 Customer PO: MIp1AwM.EMSL.corn/cadoplacelabQemsl.00m Project ID: Test Report:Asbestos Analysis of Bulk Material Analyzed Non-Asbestos Test Date Color Fibrous Non-Fibrous Asbestos Sample to HA3•KVF2 Description IOtchen-Vinyl Floor 082 11 744 4-M Homogeneity HaterogeneouslHomogeneous PLM M 198.1 Friable Not Analyzed PLM NYS 198.6 VCM Not Analyzed PLM NYS 101A NOB 09/012021 White/Beige 100.00%Other Inconclusive:Nona Detected TEM NYS 199.4 NOD 0910112021 White!"go 100.00%Dills, None Detected Sample 10 H44=WP1 Description Wallpaper 062117444-0007 Homogeneity Heterogeneous PLM NYS 196,1 Friable 0910 M021 Tan/Various 95.00%Cellulose 5.00%Non-fibrous(other) None Detected PLM NYS 108.6 VCM Not Analyzed PLM NYS 106.6 NOD Not Analyzed . TEM NYS 198A NOD Not Ahatyzad Sample 10 HA4-WP2 Description Wallpaper 062111444.0008 Homogeneity Heterogeneous PLM NY$190.1 Friable W0112021 TaN Various 95.00%Cellulose 5.00%Non-fibrous(other) None Oatocted PLM NYS 198.E VCM Not Analyzed PLM NYS 198.6 NOD Not Analyzed TEM NYS 198.4 NOS Not Analyzed Sample 10 HAS-DWI Description Drywall 0621174d4-M Homogeneity Heterogeneous PLM NYS 198A Friable 091012021 Tani White 6.00%Cellulose 36.00%Ca Carbonate None Detected 55.001A Gypsum 5.00%Non-fibrous(other) PLM NYS 198.E VCM NotAnaly2od PLM NYS 198.6 NOS Not Analyzed TEM NYS MA NOD NotAnelyzed Sample 10 HAS-DW2 Description Drywall 06211144+0010 Homogeneity Heterogeneous PLM NYS 108.1 Friable 09101/2021 Tan/White 5.00%Cellulose 35.00%Ca Carbonate NoiN Detected 55.00%Gypsum 5.00%NonAbrous(other) PLM NYS 106.6 VCM Not Analyzed PLM NYS 198,6 NOD Not Analyzed TEM NYS 198A NOS Not Analyzed Initial report tram:09102r2021 09:01:01 r AS8_79Nx 0000,08a1 Printed 9122021 9:01:03AM Page 2 of 3