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DEMO-0737-2023DEMOLITION APPLICATION i Town of Quccnsbury '742 Bay Road, Queensbury,;NY 12804 'P:518-761-8256 www.aueensbury.net Office Use Only Permit#: t>atvW _ 0� �� - 2©23 Permit Fee: $ 16':b Invoice #: in'_�A Flood. Zone? Y N Reviewed By: Demolition Location: 101 — �j7�9 qv m1�7Sbui Tax Map ID #: **AN ASBESTOS REPORT IS REQUIRED WITH ALL DEMOLITION APPLICATION SUBMISSIONS" DEMOLITION INFORMATION: 1. Where will demolition material be disposed? J".n A 11=25 2. Type of structure to be demolished: a. Residence _ d. Storage Building b. Garage e. Other! ESUILDINI, E U iFc. Business �, 55 ��Z33. What type of utilities are connected to the structure: a. Gas f. Well -Water Pump OUEEf�lSI3URY b. Fuel Oil g. Public Sewer n DC)D S c. Propane h.Other `�`� �--�--�� d. Electric _)�_ L None e. Public Water 4. Have ALL utilities (water, electric, etc.) been disconnected? Yes X 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 NAM SIGNATURE: fT DATE: Demolltion Application Revised June 2022 WNTACT 'INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL Applicant: ,Narho(s): 'Mailing Address; Po �v n . q1- ;r 7 C1 -Ce,11 Phone; *7 o 3� X�g -.9 b Lf 3 Land Line: Ernall: egi �pv i J- Q- 1-�- Lj N4 .9 Pr1rharyOwner(s): Name(s): Mailing Address, C/S/Z: Cell Phone: Land Line: V/Check ifall.work will be performed by property owner only e :C Onteactori., '(List all additional.contracturs on thebackof ihil.s. form) COntatt Name'(s): Contractor Trade- MailingAddress, C/S/Z- cd Phone:. Land Line: . "WorkerV Comp documentation ocumen,'tation must Abe submitted with this application" ,Contact Person for any questions ue _ stions "regarding . garding this project: J;r070—, CL5 vy— Land Line: Email: Dernolfflon Application Revised June 2622 R--•--•--•--R--•—'�E L4NAS.V'F ; 1 FORNITUREI/OASE NORTH, LLC 7.4C10.T➢69l-IA/I i LnUZ 9, T"M. UU:9, LLC TAX ID. 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