application Office Use Only
' ,: Permit#: S 0—Z O(Q
DEMOLITIO 2i
v E it Fee:$ CO
limn Ourrn.hu r
AUG 2 9 2019 o ce:#: r%7
742 Bay Road, Queensbury, NY 12804 J
—
P: 518-761-8256 www.queensburv.net TOWN OF QUEENSBURY
BUILDING&CODES
Demolition Location: 161 4ssovibli Poi AAA . Tax Map ID #: 'L3� -7- J"3o
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): {ul c,IetAt t3 6v•Dldip 14oyvieS
Mailing Address, C/S/Z: I Mar; cans w,.y t{c.(lch;c✓itl.( NW (2-tl$
Cell Phone: (S1 ) c247- 32E1q Land Line: _( `�7 8 ) 819 - 631 I
Email: Iu!✓e e ►� �InG,c1�,�,,,�. eo -
• Primary Owner(s):
Name(s): £ru L 3 Sa -ak Itrr't,iv
Mailing Address, C/S/Z: 1(93 f(sservl6L Poiirf , L.k�t- (Co NY 1 Zdcul C/o 5k c s
Cell Phone: _( ScS ) —7 3 t c13 23 Land Line: _(� ) bSrb - 4gLIZ
Email: SS bqs 2R CJ tmc+,r .;I. conk,
El Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): GkewIts f ricolowi �)CC�i�/ ►nq
Contractor Trade: E XC.avau1'i Ky J
Mailing Address, C/S/Z: 5y Ivan-fh Mrs -1 , I-k4So✓c rcl(S N`i' I7-$.7)ci
Cell Phone: _( 5�13 ) 36(- 11148 Land Line: _( S18 )=7c/- - 9371
Email: CcefritdMorLKoty-.};h . c,oN
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: 144k Pi\IU''G.LIS
Cell Phone: _( 5 g ) S-2 b- 32.a1 Land Line: _( -b31
Email: (ukt r��t tlty, q. L -
Demolition Application Revised February 2019
A
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? kkk4,34e. plasmic .,e44-, ]1p►r-IVl Ltivar14wd
2. Type of structure to be demolished:
a. Residence X
b. Garage
c. Business
d. Storage Building X
3. What type of utilities are connected to the structure:
a. Gas
b. Fuel Oil
c. Propane
d. Electric X
e. Public Water
f. Well-Water Pump x
g. Public Sewer
h. Other
i. None
4. Have ALL utilities been disconnected? Yes )( No
ADDITIONAL INFORMATION:
1. Two inspections may be required: an inspection to determine that utilities are disconnected, if
necessary, 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: Lt.&k -6,t,I3
SIGNATURE: DATE: V 28
Demolition Application Revised February 2019