application Office Use Only
DEMOLITION APPLICATION Permit#: i
Permit Fee:$
150
Town of Qycensbury a,
Invoice:#: 1 `y
742 Bay Road,Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net
Demolition Location: \ �fi Tax Map ID#: L • (.0 1 " ' •.
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): McI; _LA(_,
Mailing Address, C/S/Z: Z9'S kJO:nrk— (— oc0-2 '
Cell Phone: ( e4,0 ) -4 Land Line: ( ( ) _M b �Ce7
Email: 1 d.. 6R I ) P er7-7,
• Primary Owner(s): IR APR 1 1 2019 J 1
Name(s): 4Id a ,.1-� I ..
Mailing Address, C/S/Z: I lip 9UJ ENSB+
Cell Phone: _( ) Land Line: _( ) DES
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): (79 )e
Contractor Trade: c)
Mailing Address, C/S/Z: 3) 44,17120
Cell Phone: _( , 1 ) 9'//-3I 5S" Land Line: _( )
Email: ?Leer Cx t 6-,NI
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance:
Cell Phone: ( ) _ [Z--L-1/*7 I Land Line: _( ) Zjo- Z-it IcaZ
Email l�F�. c� /d , ie tLa�
Demolition Application Revised February 2019
DEMOLITION INFORMATION:
1. Where will demolition material be disposed?
2. Type of structure to be demolished:
a. Residence
b. Garage
c. Business
d. Storage Building
3. What type of utilities are connected to the structure:
a. Gas ?4
b. Fuel Oil
c. Propane
d. Electric
e. Public Water
f. Well-Water Pump
g. Public Sewer
h. Other
i. None
4. Have ALL utilities been disconnected? Yes No
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:
SIGNATUR1 DATE:
Demolition Application Revised February 2019