DEMO-0481-2021 Office Use Only
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DEMOLITION APPLICATION Permit#:
Permit Fee:$ 1 6 S .O0
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Town of Queens bary D E C E Invoice#: J 1 Z
742 Bay Road,Queensbury,NY 1 4 r
P:518-761-8256 www. uee . et JUN 2 4 2021 Flood Zone? Y (N ) Reviewed By:Csa
TOWN OF QLIEE14SBURY
BUILDING&COD`
Demolition Location: o �in��p�' e 'rlS r - ax Map ID#: 30 71,15—
NY rz�oy
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? h(we 1S e'M Y—C �cS11�
2. Type of structure to be demolished:
a. Residence d.Storage Building
b. Garage e. Other:
c. Business
3. What type of utilities are connected to the structure: TOWN OF QUEENSBURY
a. Gas_2�1_ f. Well-Water Pump BUILDING & =�ES EPT.
b. Fuel Oil g. Public Sewer X Reviewed y'
c. Propane h. Other -1,
d. Electric i. None
e. Public Water X
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: \k�yssc, A, �o o
SIGNATURE: ��dld,O,Ca DATE: ` o!�b�
Demolition Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): P1, G n r&o n
Mailing Address, C/S/Z: Ca-r-\2. Pt- Queeasbsi�, N`I' (280
Cell Phone: (51 g ) S- '38`( Land Line: �)
Email: mPlissca a yokon com
• Primary Owner(s):
Name(s): NM VL-5s P-\ - 6 1 L-,r&6n
Mailing Address, C/S/Z: at:-5 (-o 1),-. C�,� sbvc�►, N
Cell Phone: _(S(B- )33E-IF�,3434 - - Land Line:
Email: vie,\�ssa-cz-gQf3zk- 'on. Curves
❑ 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):.
Contract or 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:
Cell Phone: Land Line:
Email:
Demolition Application Revised December 2020
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