application Office Use Only
I ' Permit#: flern0 — 00C9
DEMON 11V f'PP'LI -,`TIPM
.e lS0/ Uri
� - -�� I Permit Fee:$
7bn•n nt(Liccnsbury
FEB 13 2020 u, Invoice:#: ! a
742 Bay Road,Queensbury, NY 12804
P:518-761-8256 wvvw.aueensbury.ndt -I-OWN OF QUEEN EU RY
CODES
Demolition Location:
Rd Tax MapID#: �� ( 9 - '- -3o
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**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
CONTACT INFORMATION:
oe • Applicant:
Name(s): Ac c-ovo. ►' k ---
Mailing Address, C/S/Z:
Cell Phone: i ( ) 3 161 3 7 Land Line: ( ) _.—
Email: ---
OZ • Primary Owner(s):
Name(s): /4Arov - n�L
Mailing Address, C/S/Z:
Cell Phone: I ( _) '3d. I`43 7 , Land Line: _(
Email:
❑ Check if all work will be performed by property owner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): Cot-
Contractor Trade:
Mailing Address, C/S/Z: 11 e, e titi all a( rti,:5 Anj t
Cell Phone:t (5 i? ) n(io - 14 ► Land Line: _( ) —
Email: Cdt_ bCic v.. L/ti% _v-4„it • 6V-
**List all additional contractors on the back of this form
Contact Person for Building & Code Compliance: rit„,v C,/k
Cell Phone: (51 p ) 364 • 3 6 Land Line: _(
Email: �c� ^� i. c —
Demolition Application Revised January 2020
f r • Contractor: ers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z: 17 ( ,.v._ 1i (. 4h .n f p � / X6 C(
Cell Phone: I ��.( ,s ) 1 f� rf, U Land Line: _( )
Email: (114.r, GNP a (iikk6 . Pvob�
• Contractor: Wor ers' Comp documentation must be submitted with this application
Contact Name(s):— ice ---•r•
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:L.( c" —' Land Line: _( )
Email: -
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) - Land Line: _( )
Email:
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): •
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: _( )
Email:
Demolition Application Revised January 2020
DEMOLITION INFORMATION: �l
1. Where will demolition material be disposed? tQ l
2. Type of structure to be demolished:
a. Residence
b. Garage /
c. Business _/
d. Storage Building
3. What type of uti 'ties are connected to the structure:
a. Gas
b. Fuel Oil
c. Propane
d. Electric
e. Public Water
f. Well-Water Pump
g. Public Sewer I/
h. Other
i. None
4. Have ALL utilities been disconnected? Yes No 1./-
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: Lei') A C /-'--
SIGNATURE: •
.61 ._ esi DATE: , /'9 o
2,0
Demolition Application Revised January 2020