DEMO-0762-2021 t—
Office Use Only
Permit#: �
DEMOLITION APPLICATION
Permit Fee:
'town ofQueens6eeIT
Invoice#: �
7.42 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net Flood Zone? Y N Reviewed_By:
3 LI 'Z 44p_ jCnJ .. 9 L—
a vle^K 61 f y J 2 P y
Demolitiorf Location: Tax Map ED#: 7-1 7 �-
**AN ASBESTOS REPORT-ISt REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? Y"
2. Type of structure to be demolished:
a. Residence d.Storage Building
b.. 'Garage e.Other:
c. Business❑ D I5 C E U V j
3. What type of utilities are connected to the structure: V�
a. Gas El f.Well-Water Pump OCT 14 2OLi
b. Fuel Oil❑ g. Public Sewer❑
C. Propane❑ h.Other TOWN OF QUEENSBURY
d. Electric i. None BUILDING& CODES
e. Public Water
4. Have ALL utilities(water,electric,etc.)been disconnected? YesEr 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:
SIGNATURE: DATE:
Demolition Application Revised December 2020
, 4
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): �, She„ra , d-msA
MailingAddress C S Z: I S +Z. 1f"A' , 9I-' � �l�' � N�
1 1 3 Z � -t�i
Cell Phone: -6iftd-6pis:
Email:
• Primary Owner(A:
Name(s):
Mailing Address, C/S/Z: SC�r-�, C)S
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): l~)IS wC'Y4 <Y �0'a 6C C,%V:l°}-:
Contractor Trade:
Mailing Address, C/S/Z: �� �!►s't,or�'G, L�„n� Ex-}-. , ��,{� r�__��v/ /�,f'�
LeWftene- Land Line:(513)
Email:
"Workers' Comp documentation must be-submitted with this application"
�-e)
Contact Person for any questions regarding this project:
Cell Phone: �: / 49) �_5_2 �7
Email: ` II 1
Demolition Application Revised December 2020
w
TOWN OF QUEENSBURY FILE COPY
BUILDING & CODES EPTo
Reviewed By:
Date: 0 � C E U V E
l D
OCT 14 2021
Asbestos Surve TOWN OF QUEENS
BURY
BUILDING
&CODES
Lester Chase
3219 state Route 9L
QueensUury, NY 12804
Inspection.date: 10/1/2021
N
Jt -
TOWN OF QUEENSBURY
Tort Callahan/TC Inspeddons BUILDING DEPARTMENT
Based on our limited examination,compliance
J Knotts Dr with our comments shall not be construed as
indicating the plans and sppecifications are in
Ql..eensbury,NY 12804 full compliance with the 8ullding Codes of
Inspector# 17-42926 fContractor# 109425 New York State.
cettff 513-832-9750
239.19-1-17 DE40-0762-2021
Chase III, Lonny
3219 State Rte 9L
Demolition of Garage Only
Summary of Inspection
At the request of Lester Chase an asbestos survey was performed
at 3219 State Route 9L Queensbury, NY .
Scope of the Inspection/Survey is to determine if the house
contains any asbestos prior to demolition .
Suspected Asbestos containing materials were removed and sent
out for sampling. The following samples were removed and sent
out for testing.
Homogeneous area 1( nonfriable) Asphalt roofing (no asbestos
detected)
Homogeneous area 2( nonfriable) Roof shingles ( no asbestos
detected)
Homogeneous area 3 (nonfriable) Tar paper ( no asbestos
detected)
Homogeneous area 4(friable) Cellulose board ( no asbestos
detected)
THIS REPORT SHOULD BE MADE AVAILABLE TO ANY NEIGHBORS.
THIS REPORT SHOULD ALSO BE READILY AVAILABLE AT THE
LOCATION OF THE DEMOLITION/RENOW T IC?N FOR ANY TRADES
PEOPLE ENGAGED TO CARRY OUT REPAIRS OR DEMOL IT€ON OF
THE PROPERTY.
Conclusion
No Materials were identified as containing more than 1% asbestos
material. Therefore no_asbestos abatement is required.
A copy of this report should be kept at the work site.
A copy of the sample analysis is attached to this report
t
NewY&rk State='Depaetrti ttt"of.Latia r,
Division of.4 yand Ncalth
q' License and c .!JRC ztL*08it':
State Camp+Js,dviidng 92
Albany..MY,12240`
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:-A'SBESTCIS 14ANDLING LICENSE.:,,.. _
Catlai a►}`tltia TC inspecfiait FILE NUMBER: 4,1309d25
`�•'LICENSE NUMBER:':'LU9425•'� ':�, - ' . `
`1.ICrtoltsOrive .. LICENSE CLASS: RESTRICTED
s DATE OF ISSUE: 01100b21
;-.66 nsbury',AY 12864. EXPIRATICiN.DATE:
duly+AutttorizetiA€ieprest ntalive'=. hornas; allaliati: ,
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responsibiht,`ill dldC olTdnct of or n atLtia.
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EMSL Analytical, Inc. EMSL Order. 062119949
Customer 110- TCNS29
528 hlineota Ausnue Carle Place,NY11514
Customer Po:
TcBFarc(516)997-79511(516)997.7528
^itp:f;zv:;1.ES198L rnm t radee!a[elab:c�emoi.com Project tot
Attention: Tom Callahan Phone: (516)832-9750
TC tnspections, Fax:
9 Knolls Drive Received pate: 10104I20Z1 1:26 PM
Queensbury,NY 12604 Analysis Rate: 10/06/2021-1010712021
Collected Date: 10.10112021
Project. 3219 St,Rt.9L
Test Report:Asbestos Analysis of BURG Material
Non-Asbestos
Analyzed
Test Data Color Fibrous Non-Fibrous Asbestos
Sample 10 1-RMt Description Asphalt Rooting Material
062119949-0001 Homogeneity Homogeneous _
PLM NYS 196A Friable Not Analyzed
PLM NYS 190.6 VCM Not Analyzed
PLM NYS 198.6 NOB 101=2021 Whiter Black <1.00%Min.Wool 100.00%Other Inconclusive:.None Detected.
_ TEM NYS 198A NOB 1010712021 Whitet Black 100.0(r%Other None Detected
Sample 10 1-RW Description Asphall Roofing Malenai
062119849.0002 Homogeneity Homogeneous ^
PLM NV5198.1 Friable Not Analyzed
PLM NY5108.6 VCM ---- Not Analyzed
PLM NYS 193.6 NOB 10101KMI rihita!4laclt a1.00-%Min.1Jcoi 100.40"Other tnconciusive:Nona Detected
TEM NYS 128.4 NOS 101D724021 v ltc?Black - 1017.00%,Otl,er - None Detested
sample'to 2-RS1 Description sloe`Shingles
0621253:?-000:'t Homo9enolty Horrapne00S
PLA1 NYS 198.1 Friable _ Not Analyzed
PLM NYS 198.E VCM ..` Nat Analyzed
PLM NYS 199.6 NOS io"OV-7021 INWAw slack <4.00%W..in.Wool 1130.00%001er tnconeiusive:Mont Detected
TEM NYS 198.4 NOB 10b7r2021 White,Black 100.00%o!her `- None Detected
Sample ID 2-RS2 Description Roo`SNngles
062119949.0004 Homogeneity Homogeneous
PLM NYS 198.1 Friable Not Analyzed
PLM NYS 198.6 VCM Not Analyzed
PLM NYS 198.6 NOB 10107:2021 White!Black <1.0044 Min.Wool '100.00".Other tnconctusive:None Detected
TEM NYS 198A NOB 10107F2021 Whiter 31ack 100.00 a Other None Detected
SamplelD 341`1 Description Tar Paper
0621199d9-0005 HMSfo8Cclelty ki4nY`geReb::s
PLM NY5'196.1 Friable
Nat Analyzed
PLM NYS 198.E VCM Not Analyzed
PLM NYS 198:6 NOS 10.10712021 ^slack 'IM%Min.Wool 100..00°5 Other tnconclusive:None➢elected
TEMNYS,i98.4N08 10ifl7.r2021 Black 100.00.. -r Neu.Detected
lniiial report frcm:10.072021 13-35:59
4$S_'Et>;_.70G_;00t �rin1ed 10RIZ021 i:37;03P1G Page 1 of
1=Mas'L Analytical, Inc. EMSL Order 0621/9949
44 528 ftImeala Avenue Cade Place.NY 11514 customer ID-. "fCIVS29
TeUFay:(Sir,)997-72511(51S)997-7520 Customer PO'
. . )thaaAv:ay.EhlSLcami cadeptaeclari�amsl.eam projectlD:
Test Report:Asbestbs Analysis of Bulk Material
Non•Asbestos
Arlalyxed
Test Date Color Fibrous Nan-Fibrous Asbestos
Sample lD 3-TP2 Description Tor Paper
062ilS949-0006 Homogeneity Homogeneous
PLt4 NYS 198.1 Friable NotAnalyzed
PLM NYS 190.6 VCM NotAnalyzed
PLM NYS 198.6 NOB 1007,12021 Black -1.001.Min.Woo) f00.00%Other Inconclusive:None Detected
TEM NYS 198.4 NOB 10107/2021 Black 100.00%Other Nan.Detected
SamplelD 4-M Desedplion Cellulose Board
052119949-0007 Homogeneity Heterogeneous
PLM NYS 190.1 Friable 10106f2021 Whi(e/Beige 98.00%Cellulose 200%Non-fibrous(other) Nona Detected
PLM NYS 198.6 VCM NotAnalyzed
PLM NYS 196.E NOB Not Analyzed
TEM NYS 198.4 NOB Nat Analyzed
Sample ID 4•CB2 Description Cellulose Board
D62719949-0009 Homogeneity Heterogeneous
PLM NYS 198.1 Friable 10/06/2021 Browns Beige 96.00%Cellulose 4.001/6 Na"Abrous(other) None Detected
PLM NYS 198.6 VCM N61 Analyzed
PLM NYS 198:6 NOB NotAnalyzed
TEM NYS 198.4 NOB Not Analyzed
1n19al report from:lo/07=21 13:30.1.9
,953:.3x_0009 70i?:Printed 1017/2021 1:37:02PM Page 2 cf 3