DEMO-0076-2021 L �
Office Use Only
DEMOLITION APPLICATION Permit#:
Permit Fee:$ Pr
Tos+n of Qucensbury
' Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Flood Zone? .Y. N Reviewed By:
Demolition Location: 21 Quaker Rd Tax Map.ID #: 296.18-1-1
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed?
2. Type of structure to be demolished: D
a. Residence d. Storage Building® 0
b. Garage ❑ e.'Other: F�e
c. Business ❑ ? ?Q
TOWN o ? 21
3. What type ❑of utilities are connected f. Well Water Pump ❑ BUo the structure: /CONG`��COSeUh'Y
a. DES
b. Fuel Oil ❑ g. Public Sewer❑
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: cov" '11e.
SIGNATURE: n , DATE: do2-1
Demolition Application Revised January 2021
'r
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
.Name(s): Town of Queensbury/Pine View Cemetery
Mailing Address, C/S/Z:21 Quaker Rd Queensbury NY 12804
Cell Phone: Land Line: 518-745-4476
Email: ,
• Primary O.wner(s):
Name(s): Same as Above
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
® Check if all work will be performed by property owner only
• Contractor: (List all additional contractors on the back of.this form)
Contact Name(s): //��� //
Contractor Trade.
C�r►'lr.�s4 �{n lvYtf
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for any questions regarding this project: Connie Goedert
Cell Phone: Land Line: 518-745-4476
Email:cgoedert@queensbury.net
Demolition Application Revised January 2021
Asbes' tos- Surve _
Pine View Cemetery
Town of Queensbury
21 Quaker Rd
Queensbury, N.Y.
Inspection date: 2/22/2021
Below are images of the buildings that were inspected
D
ccE 2 2 2021
TOBUILDING OF U&CODES EENSBURY
I 296.18-11 DEMO-0076-2021
Pine View Cernetery/TOQ
21 QuakerRd i
Demolition of 3 buildings
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Summary of Inspection
At the request of the Town of Queensbury an asbestos survey was
performed at Pineview Cemetery, 21 Quaker Rd Queensbury, NY .
Scope of the Inspection/Survey is to determine if the three
storage buildings contain any suspected asbestos material prior
to demolition .
The construction of the three buildings was wood and metal. The
material used for the roof covering was metal as well. No
materials that were suspected to contain asbestos were
discovered during the inspection. Therefore no sample testing is
required.
Things to note
THIS REPORT SHOULD BE MADE AVAILABLE TO ANY NEIGHBORS.
THIS REPORT SHOULD ALSO BE READILY AVAILABLE AT THE
LOCATION OF THE DEMOLITION/RENOVATION FOR ANY TRADES
PEOPLE ENGAGED TO CARRY OUT REPAIRS OR DEMOLITION OF
THE PROPERTY.
Conclusion
No Materials were identified as being suspected to contain asbestos
material. Therefore no asbestos sampling is required.
A copy of this report should be kept at the work site.
General images of the storage buildings on day of inspection
P
Please note because of covid 19 NYS Dept of Labor has granted
temporary rules for licensing. These temporary rules can be viewed at
https://labor.ny.gov/workerprotection/safiatyhealth/temporary-rules-Iicenses-
certifications-exams.shtm
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.pro ectworksrte° . his•lecnse verifes;thaual rsons-employed by the-lice ee on an asbestos project{in;l�icly York;.
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ASBESTOSCERTIFICATE
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MUST BE CARRIED ON ASBESTOS PROJECTS