DEMO-0776-2021 Office Use Only
�;�":. fi•". Permit#: ��` T"10-- 0�'1n• 242\
DEMOLITION APPLICATION �
Permit Fee.$ Ica
To«ii ofQucensbury Invoice#: �JZ�
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net Flood Zone? Y N Reviewed By:
Demolition Location: Tax Map ID #:
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION: fwa�( -f_ ) n t w
1. Where will demolition material be disposed?�Ov is 1
2. Type of to be demolished:
a. Residence d. Storage Building
b. Garage e. Other: 0��`� \X10��c. Business
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 ar V None❑e. Public Water i.
4. Have ALL utilities (water,electric, etc.) been disconnected? Yes No 0
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:
SIGNATURE: DATE: 0 0
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:
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: and 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
e
309.5-1-1.1 DEMO-0776-2021
Clark, Jason (Robert)
20 Sugarbush Rd
Removal of manufactured home
TOWN OF QUFENSBURY
BUILDING 0,C)DES DEPT.
T WN 0 QUEENSBURY
Reviewed �y: � � UILDIN DEPARTMENT
Based on ur limit d examination,compliance
Date: �'� with our c mment shall not be construed as
indicating tie plans and specifications are in
full compliance w th the Building Codes of
N New York Ifa.:.
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