application Office Use Only
•fy S = DEMOLITION Permit#: £'1^^ t ""035 - zU(9
`, "gy _, I ECEOV IS Tee:$ / �O. 06
Town of Queensbury JJ
i'i inf. �„54
742 Bay Road, Queensbury, NY 12804IIIa MQY 2 2019
P: 518 761 8256 www.queensbury.net
TOWN OF QUEENSB.JRY
BUILDING& CODES
Demolition Location: 2 2. 1 Coe I, - , W. Tax Map ID #: 30 9./3-2 -2..r
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
• Applicant:
Name(s): _-eke " L;c.c rcl;
Mailing Address, C/S/Z: 2907 1?o.4e 9 -_R4us ,h Spa , A4/ /2ozC
Cell Phone: (5-se ) 7? /-lolo'fY Land Line: ( 3--/21 ) sr/-/20 / exJ. yzy7
Email: g✓iecf,c.r.i; e° C4e,)arr}tsl,,c. Cor..,
• Primary Owner(s):
Name(s): S t,Je,e-4 s SLor c (rpbr..-};vn
Mailing Address, C/S/Z: 2'o7 Ro,,}r 9- Ball s-►..-, re4 NY / i 0
Cell Phone: ( (i ' ) 77y-/,/,yy Land Line: _(S/fl ).3"8/-/zo1 ex4. e12ti7
Email: S l i cc",0-rcl i C' S+e,,.4.-fs strop s.e-D
El Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): S,LC /c,r-4-s Sly Coreoru440,�
Contractor Trade:
Mailing Address, C/S/Z: 2ga7 c ogle 9- 8efik3o, Spot/ ,t/y /20z0
Cell Phone: (,j-/s ) 77 /-I,4,t/y Land Line: _(Srnl )s 'i- / o / exd. L y 7
Email: �1itL‘a.rcri P S4e.-J.,--4s-cliT c`.t,-) ,
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: .SlCpkn Lictiard i
Cell Phone: (VIj ) 77y-6/91-fy Land Line: ( vie ) ,'/-/20/' eX,t. (2`/7
Email: S hGc,cu'di @ S+0wu.--)ssi,rs.to....1
Demolition Application Revised February 2019
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? Yvas}c W�u�nae -e- 4- (Sc.nsr✓ago �� A) '
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 A"
b. Fuel Oil
c. Propane
d. Electric X
e. Public Water A/
f. Well-Water Pump
g. Public Sewer A/
h. Other
i. None
4. Have ALL utilities been disconnected? Yes No
"e\et-V;c, 4o \ e- d1Scor n,rcA-cd c aewio,
Sce. ®pAA-ax\,eJ tudrolsolk 5a s dew,o le cr
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:
t.
PRINT NAME: keel ca.r
SIGNATURE: i�►/d�ilt.,�i�G� DATE: S/41
Demolition Application Revised February 2019