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DEMOLITION APPLICSATION Permit#: _2_015-7, --,15:,
Permit Fee:$ 150 3,1-0r-cld
town of Qcen.;bury
Invoice:#: )
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742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net .1-1,„,t0titri
1-63
1 ernolition Location: t: • Tax Map ID#: 50a. . L
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATIO SUBMISSIONS**
D E C 1,, 4414 iF" 0
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CONTACT INFORVATION: -e.-411Pr_
p1:11: 1(71:1F:::43S19BUR Y
e Applicant:
Name(s): 6ii-W, --.LTAL, IF4Ai,/i
Mailing Address, C/S/Z: 7ciSA- ki.),,,,,, ,-.,
Cell Phone: ( t_S(„,,c.‘, ) v7 7-4,157) Land Line: ( 'i3i,c, ) Z.„7.-5,b5z1.-,:q -e: i-- (G 7
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Email: tIre-,v.-A f-D,f1, \Lift i..._..* f— 1 illet 6:. ( e, ft.il ., ;; ' . • . ' : ,, '...f '
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• Primary Owner(s):
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Name(s): 1 1 -i . 1--
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Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Li Check if all v-ork will be merfor-c:ed by hom -_,limner only
Contractor Workers' Comp docur:lentation must be submitted with this application
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Contact Name(s):
Contractor Trade: t_4.,,,dy,, -,_:b
Mailing Address, C/S/Z: 4,3/ kal,?, r,i--,41,1?f,Z, e- Al- -4-7.-17{_tthi; ,---76 U A
Cell Phone: ( s;Y42:, ) '-ii 53 Land Line:
Email: if':,),, -6511; (..:.?..k1 , if•;-,,V1
**List all additional cs:i-tractors in the back if this form
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Contact Person for Building & Code Compliance: t<A7. c,,,kt:jr, \r-k,,,,, , „, ,
Cell Phone: ( g'ire.)) i7 -e-ts T L Land Line: ( ) `2,q0-.
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Email:
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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
b. Fuel Oil
c. Propane
d. Electric
e. Public Water >6
f. Well-Water Pump
g. Public Sewer
h. Other
i. None
4. Have ALL utilities been disconnected? Yes No 26
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: t� r-,Ape �,,A ✓�� J�cs��t94-1-t./L
SIG NATU
fz9 ,. DATE:
Demolition Application Revised February 2019