application 08/13/ri020 10:02AM 5185818259 KEVIN GIRVIN PAGE 01/02
•
Office Use Only
DEMOLITION APPLICATION Permit#:_ ® — � ' G0�
Permit Fee:$ 1
Town of Queens.ury •
Invoice:#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Demolition Location: 3‘:--6 \-1 1 \cuiÔ ‘)C, Tax Map ID#: 0-9 V . )O ~I
BAN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION: -
• Aoolica7,
Name(s): k&AtN;‘)_ G\�tl1M \CV ) Et (L )
Mailing Address,C/S/Z: c - WV)
C
Cell Phone: (511, ) 36S--T5216 Land Line: ( )
Email: •4isM. &\kt\ions - kVa t cvnitA t -
• Primary Owners •
Name(s): � k) \610
Mailing Address,C/S/Z:
Cell Phone: (O ) a_ Land Line: _(
Email: t neuVpur Q9m - f1e
Q Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be sybmitted with this application
Contact Name(s):_Ze" G 1 ___GARtiU
Contractor Trade: CMG -
Mailing Address, C/S/Z: vti- '- Ay')U Lr FE C IE F c E
Cell Phone: ( ) _ Land Line: _(
Email:
G 13 � 7i7 1
**List all additional contractors on the back of this form
TOWN OF QUEENSBURY
��� BUILDENG &CODES
Contact Person for Building & Code Compliance: \I
Cell Phone: _( ) Land Line: (
Email:
Demolition Application Revised February 2019
08/13/2020 10:02AM 5185818259 KEVIN GIRVIN PAGE 02/02
4'
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? D s 1 111'Qqw\ r l (5U0)
2. Type of structure to be demolished:
a. Residence
b. Garage V
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
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: - t\C=V . Gi r if u) Cv1 f-L7 r15&c kk-.)
P
SIGNATU ` DATE: Q��?°'Z()
Demolition Application Revised February 2019