DEMO-0615-2021 Office Use Only
DEMOLITION APPLICATION Permit#: 0 20 2
Permit Fee: $ 1��
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.(,LieersbLiry.net Flood Zone? Y Reviewed Bv-c-
9.1 202-1
Demolition,
emoli 2 naLd�ation: Tax Map ID#:
- A STOS WC-M AN S IBE
DEMOLITION APPLICATION
DEMOLITION INFORMATION: '7'-A i s CL 0
rpli f C ?C—
A em-e- eL Y
s 1. Where will demolition mat2erl posed?
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W,
n�r
2. Type of structure to be �ecl:
,C-�. Rqi_____- d. Storage Building[]
b. Garage F-1 e. Other:
c. Business El AUG 19 2021
3. What type of utilities are connected to the structure: - OWN op
a. GasE�� f. Well-Water Pump ❑
BUILDING&QUe E SBUR),
b. Fuel Oil F❑I g. Public Sewer C 0 D r--s
c. Propane F-1 h. Other
d. Electric BI- i. None El
e. Public Water 2-
4. Have ALL utilities (water, electric, etc.) been disconnected? Yes ❑ No
ADDITIONAL INFORMATION: CZ I le Ae 4"e /'e
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: /,-"--
SIGNATURE: z6n_" Z/_6�_ DATE:
Demolition Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A licant:
Name(s): 10nl2c
Mailin!Address, C/S/Z: 01, 1�25� I-er9161✓ 31 v ���6' ��rs � AV
Cell phc Land Line:
Email: Sis/kca dvn 6�wC lVah a , Co,,
Primary Owner(s):
Name(s): Barr,e a 5
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