DEMO-0266-2022 Office Use Only
Permit#: n�,o --
j DEMOLITION APPLICATION _ _
/ °`Permit Fee: �®
Town of Queensbury L� a L
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y �eviewed)B .
Demolition Location: 130 iP\V\OVe 14—MV NE Tax Map ID #: 309.2—k 32_
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed?
2. Type of structure to b demolished:
a. Residence to
d. Storage Building
b. Garage e. Other:
c. Business
3. What type of utilities are connected to the structure:
a. Gas f. Well-Water Pump
b. Fuel Oil g. Public Sew
c. Propane h. Other ���J�-
d. Electric y / i. None
e. Public Water e/
4. Have ALL utilities (water, electric, etc.) been disconnected? Yes No
ADDITIONAL INFORMATION:
1. Two inspections are required: an inspection to determine that utilities are
disconnected, 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: G�j
SIGNATURE: l 1 DATE. �� (� 21�
Demolition Application Revised February 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: 1d�
Name(s):
Mailing Address, C/S/Z: Z�\ \C\ Eu-� nLa3�c-__
Cell Phone: Land Line:
40a
• Primary Owner(s):
Name(s):
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 February 2022