DEMO-0067-2022 Office Use Only
Permit#: ��10 ' uOb�'DEMOLITION APPLICATION
f Permit Fee:$ 1%Q0 �
Town of Queensbury (p
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y Reviewed
De tio�Location: Tax Map ID #: 5�3Yee 2 q6. �3—
**AN ASBESTOS REPORT IS REQ
DEMOLITION APPLICATION S
DEMOLITION INFORMATION: FEB 2 3 2022
1. Where will demolition material be disposed? TOWN OF QUEENSBURY
BUILDING&CODES
2. Type of structure to be demolished:
a. Residence d. Storage Building❑
b. Garage ❑ e. Other: ��D
/ M C�
c. Business ��l�S/m� Ste '
3. What type 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 9
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: __ o
PRINT NAME: SJ%���
SIGNATURE: DATE:
Demolition Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line: :
Email:
1� y
hoo
Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
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):
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:
Cell Phone: Land Line:
Email: >
Demolition Application Revised December 2020
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