DEMO-0039-2022 Office Use Only
DEMOLITION APPLICATION Permit#:
Permit Fee:
Toxwi-of Qu�`.,
Em
Invoice#: �g�J
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y Reviewed `
Demolition Location: Tak-Map ID#: 30 z.. -1-1 9
**AN.ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed?
2. Type of structure to be demolished: D
a. Residence d.Storage Building❑
b. -Garage e. Other:
c. Business❑ OF QUEENSl3URY
TOWN
LD►NG&CODES-
3. What tvpe-.of utilities are connected to the structure:
a: Gas ❑ �f. Well-Water Pump ❑
b. Fuel Oil ❑ g. Public Sewer❑
c. Propane❑ h. Other
d. Electric❑ i. None
e. Public Water El
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: �<fv.^ "C%VVo%e"10^ A
SIGNATURE: DATE: ( °�'ZZ
Demolition Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE,.PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): t�AaY{ti H A r►,r>n��.rr 7j{„� 1w,,,.,-two+
Mailing Address, C/S/Z: S.I~ C.rJ-c
Cell Phone: Land Line: 12-Tra-i
Email: Sid-?q?-1220
• Primary Owner(s): 1
Name(s):
Mailing Address, C/S/Z: Sat °` s aLi.0 V-c.
Cell Phone: Land Line:
Email:
Xtheck 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**
Contact Person for any questions regarding this project: V-e J.;,
Cell Phone: Land Line: 5/8-ZJZ..S71 a c� i l
Email:
j l.6-1 f 3- 12? 0 Lam
Demolition Application Revised December 2020