Application Office Use On]DEMOLITION APPLICATION Permit#: P6A10 - CL-30
Permit Fee:$
InHn o(Quccnshuq• ' g
Invoice#:
742 Bay Road,Queensbury,NY 12804 /L,l
P:518-761-8256 www.oueensbury net Flood Zone? Y ( ry / Reviewed By: kAS _
Demolition Location: t` Tax Map ID It: 3`� �� a3 • }� —r ���
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? 45 k F"re Jw,a N �KCe✓M ("`y
2. Type of structure to be demolished:
Residence d. Storage Building❑
Garage ❑ e. Other:
c. Business ❑
3. What type of utilities are connected to the structure:
a. Gas j
❑ f. Well-Water Pump❑
b. Fuel Oil ❑ g. Public Sewer❑ I
c. Propane ❑ h. Other
d. Electric ❑ i. None
e. Public Water❑
4. Have ALL utilities (water, electric, etc.) 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: -�/£ ��c� d! v� /q�C41 N o r✓(
SIGNATURE: ( DATE:
Demolition Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Mailing Address, C/S/Z:
Cell Phone: Land Line: 1:9Lr fl S F`¢
Email: -�—e8 - /(3s-
caXOt-v01- na-- 7K7-5;-F/-7
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• Primary Owners :
Name(s): —�Ir, W,
Mailing Address, C/S/Z: C
Cell Phone: Land Line:
Email:
/71rm t l -ft�.7 Al
poe FCheck if all work will be performed by property owner only
• Contractor: (List all additional contractors on the back of this form)
Contact Name(s): C VtA-„t, 'C- 4-c,+ '�y 7rc
Contractor Trade: �19��.r ��,f c(,q ^J
Mailing Address, C/S/Z: S-K
Cell Phone: Land Line: -t<saa�- AA( (d-P2 F
Email: J "�9- - 7c(7- y' 7 /
"Workers' Comp documentation must be submitted with this application"
Contact Person for any questions regarding this project: �.� r O®/a¢rCq•v own`
Cell Phone: Land Line:
Email:
Demolition Application Revised December 2020