DEMO-0386-2022 w
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Office Use Only
DEMOLITION APPLICATION Permit#: O
Permit Fee:$�l��J
Town ofQucensbury
Invoice#• 7i-
742 Bay Road,Queensbury,NY-12804 - - �:.,�evieinrp&B
P:518-761-8256 -.www.gueensbury.net- FloodZone? Y '
Demolition Location: `N Z C(CAW1 V8 Tax Map ID#:
**AN ASBESTOS REPORT IS REQUIRED WITH ALL,
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION-INFORMATION:
1. Where will demolition material be disposed? )kcka ' 1U
2. Type of structure to be demolished:
a. Residence. , , -d.Storage Building
b. Garage e.Other:
-E• rr - .E •9!•�:
c. Business _.
3.. -What type of utilities are connected to the structure: 'JUN .1 4' 2022 `
a.. Gas._. f.Well-Water Pump.
b. Fuel Oil _. ..g..Public Sewer
c., Propane—;,,.' ' _ i ,A h-Other, , % TOWN OF QUEEN8BURY
d. Electric I.None* BUILDING&'CODES
e. Public Water
4. Have ALL utilities(water,electric,etc.)been disconnected? Yes - No.
ADDITIONAL INFORMATION: -
1. Two inspections-are required: 'an inspection to determine that utilities'are
disconnected,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.G
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 abgve:
PRINT NAME: — I IJ �I Lk
SIGNATURE: DATE: ZZ
Demolition Appllcatlari Revised February 2022
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CONTACT INFORMATION:PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): ))-I CYO
Mailing Address,C/S/ : L4(A C.- dq-vNk1,% lrboq
Cell Phone:-- J b b- -- Land Line:
Email: C A- (6VA
• =Prima Owner as .
Name(s): ,� CKkAL-
Mailing�Address,C/s/Z: ' BIZ' i 09 .
Cell Phone: 1IUD L49,16 Land Line:
Email: In A L, 60..Ij0.A &I •C.b
Kche.ck 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:
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: 1&j jM;'6jCJ
Cell Phone: 51ib Zk6`L- ,jtl Land Line: N 6.
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Email: h.bN _douAQ Cad,..
Demolition Application Revised February 2022
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