DEMO-0645-2022 Office Use Only
DEMOLITION APPLICATION Permit#: Z�Er 6
/ Permit Fee:$ 11�J
Town of Queensbury �,
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By:
Demolition Location: / S g/ &�, fl0, Tax Map ID#:
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? c Y',� �MICUu kv-v--
ice, s evtr�
2. Type of structure to be demolished:
a. Residence-A- d. Storage Building
b. Garage- d e. Other:
c. Business DD ;,
3. What type of utilities are connected to the structure: KCT202-� J
a. Gas f. Well-Water Pump
b.- Fuel Oil g. Public Sewer TOWN OF QUEENSBURY
c. Propane h. Other BUILDING&CODES
d. Electric _ L None
e. Public Water
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: /c D. c4IL-4 e-E
SIGNATURE: DATE:
Demolition Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): �_�
Mailing Address, C/S/Z: 1 PtZIT-` G ff L if 0 e— ® e c y•Cell Phone: Land Line: S/
Email:
• 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): Mckkky-%(9- Combs
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: \\C0&-vt`"
Cell Phone: Land Line:
Email:
Demolition Application Revised June 2022
RIA-50,
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MICHAEL CANALE
RE: Service Removal for Building Demolition 10/25/2022
To: MICHAEL
This letter is to confirm that, per your request, National Grid has confirmed electrical
service and meter have been removed at 1581 BAY RD LAKE GEORGE NY 12845.
The work was processed on work order #30677623, and meter # 28459319, was
removed. If you have any questions or need further assistance, please feel free to contact
us at 1-800-260-0054.
Sincerely, D E C E 0 V
OCT 2 6 2022 11
Customer Connections TOWN OF QUEENBBURY
BUILDING&CODES
Nationalgrid