application Office Use Only
DEMOLITION APPLICATION Permit#: 1J0 - �}cl• ��'
Permit Fee:$ 't!jo
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Invoice:#: 22o b
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.gueensburV.net
Demolition Location: c Tax Map ID #: Zaj • '� ) " ��
**ASBESTOS REPORT IS REQUIRED FOR STRUCTURES_BUILT PRIOR TO 1974**
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CONTACT INFORMATION: 1 , AUG 20th
3 1
TOWN OF QUEENSBURY
•
Applicant- SU!OiNG&C0rES
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Mailing Address, C/S/Z: 5 "-R.. �Ls� 10s �c'S'vn )S V, 12&35
Cell Phone: S ) :2'71 041q ') Land Line:
Email: A AAk.b4I LW k (Orn
• Primar Owners
Name(s): ')V C--
Mailing Address, C/S/Z: S 45 Oc &83
Cell Phone: _( SIS ) '79 f ni/,9 2 Land Line: _( )
Email: A*,zbyt ) C-+h
• Contractor:
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: Ac�
Cell Phone: K IC ) 0" Land Line: _( )
Email:
Demolition Application Revised June 2017
DEMOLITION INFORMATION:
1. Where will demolition material be disposed?
2. Type of structure to be demolished:
a. Residence
b. Garage X
c. Business
d. Storage Building
3. What type of utilities are connected to the structure:
a. Gas
b. Fuel Oil
c. Propane
d. Electric
e. Public Water
f. Well-Water Pump
g. Public Sewer
h. Other
i. None X
4. Have ALL utilities been disconnected? Yes 3( No
ADDITIONAL INFORMATION:
1. Two inspections maybe 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.
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: 441%'\r
SIGNATURE: 410j,-b, -Z'QI DATE:
Demolition Application Revised June 2017