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DEMO-0157-2023 Office Use Only DEMOLITION APPLICATION Permit 2-t 26 Permit Fee: $ 11gC5 Town of(_)uCells Ur.1 Invoice#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensburv.net- Flood Zone? Y N Reviewed By: l�qq 5-Y(A�e_ I&AIC Demolition Location: Lake d?,e6�t N Y /JVA _ Tax Map ID #: C) S6 A RE-, 01 IS " l AETT ZRED IA l,,F T H A L L DJEMOLITION, APTILDIDATIEDN SUBM1SS_P,_0NS*-' DEMOLITION INFORMATION: 1. Where will demolition material be disposed? NO 2. Type of structure to be demolished: a. Residence d. Storage Building b. Garage_ e. Other: c. Business D F` C E 9 Vj7 Lt LD 3. What type of utilities are connected to the structure: APR 12 22023 a. Gas f. Well-Water Pump b. Fuel Oil g. Public Sewer TowN OF QUEENSBURY c. Propane h. Other BUILDING&CODES d. Electric V L None e. Public Water r/� 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: 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: 9 c5 /&Mk LA,-P eo,- Cell Phone: 'l 0c?F Land Line: Email: C- cca/i7 jr r) d9?@ 5Yah00- �CJ�►-� • Primary Owner(s): Name(s): Mailing Address, C/S/Z: i�cy9 e6 7e NY /a8'l-1,S— Cell Phone: cS/,F 796 9?9F Land Line: Email: Cv/V? 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: S/1? 79lz Land Line: Email:_ ctc`/i inr� C2lr 6- yei 4&'9- CO1'.1 Demolition Application Revised June 2022 . ....... .. _.._..._ ._.. ' . 1_ ..... ....... .. .. ... 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