DEMO-0297-2021 Use O Office nIV
DEMOLITION APPLICATION
Permit#:. �t o=U�� 7
ltiD 0 t Fee:$ I. o .� 00
Town of Queensbury D I i e#:
742 Bay-Road,Queensbury,NY 12804
P:518-761-8256 www.ciueensburv.net APR 3 O 2021 Zone? Y N Reviewed By:
TOWN OF QUEENSBURy
BUILDING&CODES
Demolition LocaoohAj Tax Map ID#:
*AN ASBESTOS REPORT IS REQUIRED WITH. ALL.
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed?
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2. Type.of structure to be Aerriolished:
a. Residence d. Storage Building[]
b. Garage Q e. Other: �Sw�� �� Poo I
C. Business Q �Y'��-°U`n
3. What type of utilities are connected to the structure:
a: Gas Q f.Well-Water Pump 0
b. Fuel Oil❑ g. Public Sewer❑
c. Propane 0 h. Other
d. Electric c, i. None❑
e. Public Water[]
4. Have ALL utilities (water/.electric -etc been dis onnected? Yes❑ No�] 16dri c u;
Wised� Afa {
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ADDITIONAL INFORMATION-. �'�"`�l°H"q 0
L 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-124) 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: a w+-e-S
SIGNATURE: GL ►-.ih6 DATE: 0�9/02 j
Demolition Application Revised December 2020
CONTACT:INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): �G.w►�.g R-P�vl l
-Mailing Address, C/S/Z: S f3�ellows Ga��l� rt5�w ivy
'Celi Phone: Land Line: 518- 7qa- Li &qq
Zlo-7s2$
• Primary Owner(0:
Name(s):
Mailing Address, C/S/Z: �a��a5 a bdvf✓
Cell Phone: Land_Line:
Email:
[96eck 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: _::J4tnr,5
Cell Phone: Land Line:
Email:
Demolition Application Revised December 2020
TOWN OF QUEENSBURY 1C
BUILDING & CODES DE ate-
.
Reviewed
Date: 6
TOWN OF QUEENSBURY
BUILDING DEPARTMENT
` Based on our limited examination,compliance.
with our comments shall not be construed as
indicating the plans and s ecifications are in
p
full compliance with the Building Codes of �
New York State.
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ION -� 0 6)
D -
3 0 202-i
TOWN OF QUEENSBURY
BUILDING&CODES
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