DEMO-0085-2023 _ s
Office Use Only
DEMOLITION APPLICATION
Permit#:
Permit Fee:$
Town of Queensbury
Invoice#: 1650
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y Reviewed B
Demolition Location: e`ne-116 cl_ Tax Map ID#:
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? � Drivyi oGo rPraftt-
y
2. Type of structure to b emolished:
a. Residence (/ d. Storage Building
b. Garage e. Other: CEO
c. Business
3. What type of utilities are connected to the structure: NAR 6 3 2023
a. Gas V-, f. Well-Water Pump TOWN O�a o y
Qi) _N s i 9 `l b. Fuel Oil g. Public Sewer BU(L�►i 0 OOP
c. Propane h. Other
d. Electric 7 i. None
e. Public Water Vz
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.
have read and agree to the above:
PRINT NAME:�( n IS V� �
SIGNATURE: �1 - DATE:
Demolition Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Vknj3 w-
Mailing Address, C/S/Z: q3 . ;neh
Cell Phone: ('S. r Cqr> Land Line:
Email: Le--e-Beq 65I5 0qWlk►' -co^
• Primary Owner(s):
Name(s): I6a 1Cl 5 S c� 14 y,4yyk p `'i' -R,,13 &f i1 W��
Mailing Address, C/S/Z: d 0 i3 y
Cell Phone: y Land Line:
Email: VC) m mCYyley-yaMpV 0 aVYia c0"
❑ Check if all work will be performed by property owner omy
• Contractor: (List all additional contractors on the back of this form) � s
Contact Name(s): 41h; Deli� � ��r
Contractor Trade:
Mailing Address, C/S Z: � 1306 A Lh mby
Cell Phone: Land Line: .-2 10 ` ,--23q y-
Email: -9. . L 4 ye-16e j- k-7g G nl� Ra utpla
**Workers' Comp documentation must be submitted with this application**
Ha,,vd a+� aulmj @ g(Y)aL1 d cri"
Contact Person for any questions regarding this project: oft)
Cell Phone: JAI V- CT-3- aq5-)- Land Line:
Email: 12eboV RG('_CMCA i` o C b ram,
Demolition Application Revised June 2022
Parcel ID : 308.19-1 -45
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0 37.5 75 150 ft
0 10 20 40 m
308.19-1-45 ®E -®085-2023
Kramer, Karissa & Denis
fl . 43 Pinello Rd
Demolition of manufactured home
Map Produced by Queensbury GIS. Map is for General Reference Purposes Only