DEMO-0327-2021 Office Use Only
Permit#:
DEMOLITION APPLICATION
Permit Fee:$
Town of Queens bury
\ � � Invoice:#: 'J�l
742 Bay Road,Queensbury, NY 12804
P: 518-761-8256 www.queensburV.net
Demolition Location: 2 0�� 1� ' � Tax Map ID /
**AN ASBESTOS REPORT IS REQUIRED TH ALL
DEMOLITION APPLICAT NS**,
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CONTACT INFORMATION: MAY o 9 Z
• Applicant: TOE OF QUECOD CRY
Names : BUILDING&
( ) P TT I�G X 1 i✓A iv D
Mailing Address, C/S/Z: Zq Swn e--F -Trc-. I aLitervSLc,!),�,, /yl/ 12 RO V
Cell Phone: ( 5'lq ) Land Line: )
Email: P be I ah .�vg _GZaI G m ►^
• Primary Owner(s):
Name(s): DA nij4,n jvn.5 �y J-� -4 rgA-ML
Mailing Address, C/S/Z: PC 13!h!� 4J2G5 d L-tee,�.u►-r4, A/y I S&OL/
Cell Phone:_( ) Land Line: _( S/S )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): (3-1—&Ne,
Contractor Trade: _ �2vr �Iny,�+�S fz-x cpti
Mailing Address, C/S/Z: / C -71+ C;r,54ac /Y/ /,z?Z/.
_ Cell Phone: _( 5f`2 ) fe - 5 Land Line: _( )
Email: -t'�ornrr5./ /�Sri�r<< C •�
"List all additional contractors on the back of this form
Contact Person for Building & Code Compliance:
Cell Phone: _( 18 ) 2&b - Land Line: _( 1�1 ) 742-2G; ?,0
Email: P�-e a* 2c5 ao tF CPm
Demolition Application Revised February 2019
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DEMOLITION INFORMATION:
1. Where will demolition material be disposed? f-
2. Type of structure to be demolished:
a. Residence
b. Garage
c. Business
d. Storage BuildingG
3. What type of utilities are connected to the structure:
a. Gas
b. Fuel Oil
c. Propane
d. Electric_X_
e. Public Water
f. Well-Water Pump
g. Public Sewer
h. Other
L None
4. Have ALL utilities 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: �i4TR 1 G Ic 6r1,AN)-2
SIGNATURE: f/�Gt �,d' DATE: S /lJ 2f
Demolition Application Revised February 2019
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E C E I U E
TOWN OF QUEENSBURY
BUILDING&CODES
Asbestos
Survey
• Game
1:1 Ridge '•
Queensbury, :14
Inspectiondate: 1 1 1
S � .
1 Inspections
KnoLLs Dr
Queensbury, il4
• 1
Summary of Inspection
At the request of Dunhams Bay Fish and Game Club an asbestos
survey was performed at 2080 Ridge Rd Queensbury, NY.
Scope of the Inspection/Survey is to determine if the shed
contains any asbestos , prior to demolition.
While due diligence was performed renovations have been done
over the years and may prevent complete disclosure of the.
materials inspected.
Suspected. Asbestos. containing materials were removed and sent
out for sampling. The following samples were removed and sent
out for testing.
Homogeneous area 1( friable), shingle samples were collected
from the roof (tested negative)
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
A copy of this report should be kept at the work site.
A copy of the sample analysis is attached to this report.
New-Yoik State;—,`Departrnenbof.Lab6i
Division of:Safety and Health:''
= A License and Certificate onitl t
State Campus,Building 12'
Alban NY 12240
%.. =ASBESTOS HANDLING LICENSE_- z
Thomas-M.Callahan.dlia^TC inspections,::,; `=—FILE NUMBER: 187`109425 r
r
:.: LICENSE NUMBER:, 1'09425
1 Knolls'Drive LICENSE CLASS: RESTRICTED
DATE OF ISSUE: 01/08/2021
` Queensbury NY 128�04 - ':EXPIRATION DATE: 01/31/2022
DulykAythorized Representative'=,Thomas%Gaiiah,`fi: ;
This license lias been issued in accordancc,ivith',aspplicalilc pro'visioiWof-Article:30-of the Labor Law of New York'State and or
the Ne>v:Y'o"rk Staie Codes,Rulcs'and;Rcaulation 12.NJYCRR Part 56) ifiibje isisct to suspension or revocation`for a(1)
serious violation of state,federal or local laws witli,regardao the conduct ofan'asbestos'project,or(2)demonstrated'lack of
responsibitiiy in lh Conduct of any,jobiinvolvidg�asbestos of asbestos ma[enal
ni
This license is valid only,,for the contractor,nani'6&'bbve and'thisaicense or`a;photocopy must lic'0iontincritly displayed`at the
asbestos project.worksite,'This'liccnse verifies that=all'persons einployed:by-the licensee on an hsb'estos project-in New York
State have becn:issticd an Asbestos Certificate;appropriate for_ilie-tGc.,cf work-thcy perform,by tha New York State'
Departtitent of L'a6or. "
Eileen M.Franko. Director
SH 432(8/12) For the Commissioner of Labor
.STATE OF NEW YORK-DEPARTMENT OFLABOR -
ASBESTOS CERTIFICATE.
THOMAS M.CALLAHAN
CLASS(EXPIRES) '
�. D INSP(12/21)'
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_ 13fw1L'i 9847tJ'?,Y1
MUST BE CARRIED ON ASBESTOS PROJECTS "I
EMSL Analytical, Inc. EMSLOrder: 062002593
528 Mineola Avenue Cade Place,NY 11514
Customer ID: TCNS29
TellFax:(516)997-7251 1(516)997.7520 Customer PO:
hop:/Aw .EMSL.com/mrieplacelab@emsi.com Project ID: .
Attention: Tom Callahan Phone: (518)832-9750
TC Inspections Fax:
1 Knolls Drive Received Date: 02/04/2020 12:39 PM
Queensbury,NY 12804 Analysis Date: 02/06/2020
Collected Date: 01/30/2020
Project: 2080 Ridge Rd
Test Report:Asbestos Analysis of Bulk Material
Non-Asbestos
Analyzed
Teat Date Color Fibrous Non-Fibrous Asbestos
Sample ID RS1 Description Roof Shingle
062002593.0001 Homogeneity Homogeneous
FILM NYS 198.1 Friable Not Analyzed
PLM NYS 198.6 VCM Not Analyzed
FILM NYS 198.6 NOB 02/06/2020 Black <1.00%Glass _ 100.00%Other Inconclusive:None Detected
TEM NYS 198.4 NOB 02106/2020 Black 100.00%Other None Detected
Sample ID RS2 Description Roof Shingle
062002593.0002 Homogeneity Homogeneous
FILM NYS 198.1 Friable Not Analyzed
FILM NYS 198.6 VCM Not Analyzed
PLM NYS 198.6 NOB 02/06/2020 Black 0.00%Glass 100.00%Other Inconclusive:None Detected
TEM NYS 198.4 NOB 0210612020 Black 100.00%Other None Detected