DEMO-0689-2021 r ' Office Use Only
�~ DEMOLITION APPLICATION Permit#:
i Permit Fee:
Town of Queensbury
Invoice#: ,
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net Flood Zone? Y N Reviewed By:
Demolition Location: Tax Map ID#: 2_;tn.
**AN ASBESTOS REPORT IS REQUIRED WITH ALL
DEMOLITION APPLICATION SUBMISSIONS**
DEMOLITION INFORMATION:
1. Where will demolition material be disposed? ACE` CA%zT%ru v
2. Type of structure to be demolished:
a. Residence d.Storage Building❑
b. Garage❑ e. Other: C,Ag„N E C
c. Business El1
3. What type of utilities are connected to the structure:
SAP 15 2021
a. Gas❑ f.Well-Water Pump❑ �"
TOWN OF OUFBNSBURY
b. Fuel Oil ❑ g. Public Sewer❑ BUII-DING&CODES
c. Propane❑ h. Other
d. Electric❑✓ i. None❑
e. Public Water❑
4. Have ALL utilities (water, electric, etc.) been disconnected? Yes[✓]r 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:
PRINTNAME: 'DOJGLjqS Me CALL_
SIGNATURE: k DATE: a—7—Z,1
Demolition Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 0006LAS MGCAW
Mailing Address, C/S/Z: 1489 Cowvcv.� �.T Zq Nasrn� Gnu ��' IZy,3
Cell Phone: SY,,,Vnd Line: $'jg-zsi-3(+t 4
Email: (h c C Att .K Q IVeofftt4A Nez .IV%T
• Primary Owner(s):
Name(s): $TU AV-T A UN010- Z"P-A)lb
Mailing Address, C/S/Z: S NuroHES Ca imav► SL%vV6F-ZLArV0S NY. I7- 15,1
Cell Phone: 5►g Land Line:
Email: 339-� 484
�TbAeT , ZosffA1BEQ& {So @ G Mait., LOrvX
❑Check if all work will be performed by property owner only
• Contractor: (List all additional contractors on the back of this form)
ContactName(s): C, JZANDaL u lt�XCAUaTI'a& PNL
Contractor Trade: r X C AV 4r4,,V
Mailing Address, C/S/Z:
Cell Phone:y,a%4and Line: 619 143 • 6 y 3 1
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for any questions regarding this project: 61-4s MGCa L-L-
Cell Phone: 5'1 a Land Line: 5/$-ICI - 3&1 Q
Email: *)44-J415-
rMe Ca t . K Q. If¢o a-}tent nth .Q$
Demolition Application Revised December 2020
f
Asbestos
Stuart Rosenberg 239.7-115 DEMO-0689-2021
73 Knox Rd Rosenberg, Bonnie
Assembly Point, NY 73 Knox Rd
Inspection date:8/17/2021 Demolition of SFD/Cabin_
Tom Callahan/TC 9nspections
1 Knolls Dr
®ueensbury9 NY 12504
Inspector# 17-42926/Con_tractor 109425 m-�
cells 518-832-9750FE �
� 5 Z�23
TOWN OF QUEENSBURYBUILDING & CODES DEPT. �UEENSBURY
G& CODES
Reviewed By:
'"y
Date:
FILE �®PY
At the request of Stuart Rosenberg an asbestos survey was
performed at 13 Knox Rd Assembly Point, NY .
Scope of the Inspection/Survey is to determine if the house
contains any asbestos prior to demolition .
Suspected Asbestos containing materials were removed and sent
out for sampling.-The following samples were removed and sent
out for testing.
Homogeneous area 1( nonfriable) asphalt shingles (none
detected)
Homogeneous area 2 (friable)joint compound (none detected)
Homogeneous area 3 (nonfriable) cellulose board (none detected)
Homogeneous area 4 (friable) drywall (none detected)
Homogeneous area 5 (nonfriable) kitchen vinyl floor (none detected)
Homogeneous area 6 (nonfriable) bathroom vinyl floor (none
detected)
Homogeneous area 7 (nonfriable) porch vinyl floor (none detected)
Nags too Roe
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
J
PEORLE ENGAGED TO CARRY OUT REPAIRS OR DEMOLITION OF
THE PROPERTY.
Conclusion
No Materials were identified as containing more than 1% asbestos
material. Therefore no asbestos, abatement is required.
A copy of this report should be kept at the work site.
A copy of the sample analysis is attached to this report
RtemV&k State'-Departn*nt-of Labdit-,: ..
Division oiSatatyendHealth `a" "s:•
License and C9ittficat®UnRj
State C2inpus,6uildltig 12'
A16any..NY 12240 r..
HANDLING LICENS
tlttimas M.Callalian'i16a TC inspections: ,FILE NUMBER: ,11.109425
LICENSE NUMBER',i09426``'-
1,ISnalls prive; r'✓ LICENSE CLASS: RESTRICTED=k.,.`"
DATE OF ISSUE: 01/08/2021
:k'Queiiinsbury,�NY 12804 EXPIRATItQW DATE: 01/31/2022
Duly.Authariaed Representative'-=S;7ttomas.Calla_tian: _
This ticenct'slhas been issued in aci:t 6nce with applicalitc:piuuisio4is o'f`Aitiole:3Uof the Lafi r Law of New'Yprk'Sfateand of•
the New-YoJ Sfet'I Codes,Rules_"ii RQulatioiis'a('2NYCRR Pari34._ it isauiiject to suspension or revocation fbr a(1)
senors vioiatioii of state,federal of local lalvs% regard tadte conduet'of ati'si gstos projeet.or(2)dcmotisimted,iac_k of
respoaNbility in theconduct of anyjob nvolving�asb#s ,qr asbestos impterial:
>,L^-'-r.._Y '�� e _:. 4Y:�;iL9 tv__„'>;:'�E-.wy;..•._d .., .. _ r.
This, ceiisc Nyalid oiily,for the contractor nai ied aliope and this license or a°:p6otocopy.most be.prominehtly displayed at the
asbestds,project worhsitev':This"license verifies[hacall,' emons employeii byahe licensee oman asbcstoe.proj-, A[etvVYork
State t'&*'q beenassped an`Raihestos Certificate,appiopriate_far'ilie;typeofi o6&they perform,by the New York.Bfetc
'"`
y :,-Eileen M.Franko. Director
SK 432(6112) ry "{ ? For the Commissioner of Labor
STATE OF NEW YORK-DEPARTMENT OF LAR01t -
ASaESTa.S CEIn]M-11
THOUAS'{F9 CAU VIAtl1
6AS.S(gPIFiES); '
,
MUST BE CARMED ON ASBESTOS Pit zcn ,.
r
EMSL Analytical,One. EMSLOrder: 062116827
528 Mineola Avenue Carle Place,NY 11514 Customer ID: TCNS29
TellF=(516)997-7251 1(516)997-7528 Customer PO:
mtp:Ilwww.EMSLcom l eadepjacelab@emrJ.com Project ID:
Attention: Tom Callahan Phone: (518)832-9750
TC Inspections Fax:
1 Knolls Drive Received Date: 08/1912021 11:00 AM
Queensbury,NY 12804 Analysis Date: 08/23/2021
Collected Date: 08/18/2021
Project: 73 Knox Rd.
Test Report:Asbestos Analysis of Balk Material
Nan-Aebeatas
Anulymd
Test Data Color Flbroua Non-Fibrous Asbeotae
Semple ID RS1 Doscription Roof Shingles
02116e27-0091 Hamogeealty Homageneous
PLM NYS 198.1 Friable Not Analysed
PLM NYS 188.0-wire Not Analyzed
PLM NYS 198.6 NOB 081232021 Black!Green 1.10%Glass 98:90%Other Inconclusive:Norte Detaehd
TEM NYS 198A NOS 081232021 BlwW Green 100AD%Other None Detected
SamPla'ID RS2 Description Roof Shingles
0 62116 8 2 7-=2 Homogenety Homogeneous -
PLM NYS 198.1 Friable Not Analyzed
PLU NYS 19SA VC14 Not Analysed
PLM NYS 199.8 NOS 081232021 Black/Green <1.00%Glass 100.00%Other Inconctualvo:None Detected
TEM NYS 198A NOR 08232021 Bleckl Green 100.00%Other None Detected
srrmplela .Cal Doscripton Cellulose Board
062116827-006 Homogaaalty Homogeneous
PLM NYS 198.1 Friable 0a1232021 Brown 92.00%Cellulose 8.00%Non-fibrous(other) None Detected
PLM NYS 198.6 VCN Not Analyzed
PLM NY814CO NOB Not Analyzed
TEM NYS 196.1'HOB Not Anafyzod
Sample ID C82 Deaariptlon Cellulose Board
0 6 2 1168 2 7.0064 Homogeneity Homogeneous
PLM NYS 198.1 Friable 08232021 Brown 95.00%Cellulose 5,00%Non-fibrous(other) None Denoted
PLM NYS 1®6.e yem Not Analyzed
Pw NYS 108.6 NOB Not Analymd
TEM NYS 198A NOB Not Ami4med
8ampla.ID DW1Jolnt Compound Description Drywall
002116827--0005 Homogeneity Homogeneous
PLM NYS 198.1 Frloblo OSM312021 While 09.00%Ca Carbonate Nano Deboatod
4.00%Mica
7.00%Non-fibrous(other)
PLN NYS 196.E VCM Not Analyzed
PLN NYS 198.6 NOB Not Analyzed
TEM NYS 12&4 NOB Nat Analyzed
Initial report from:08232021 11:50A7
ASS 196r 0009 0001 Printed 8/232021 11:50r50AM Page 1 of
EMSL Analytical,Inc. EM5LOrder: 062116627
Customer 10: TCNS29
528 Mineola Avenue Cade Place,NY 11514
TellFax:(516)997-7251 1(516)997-7528 Customer PO:
httpJNnvw.EMSL.com I cedeplaulab@emsl.com Project ID:
Test Report:Asbestos Analysis of Bulk Material
Non•Aaboatoe
Analysed
Tout Defy Color Fibrous Nan-Fibrous Asbestos
Sample lD DW1-Drywall Description Drywall
062116827-CO SA Homogeneity Heterogeneous
PLM NYS 108.1 Frlabta U812312021 BTW'W Gray 6.00%Cellulose 14.00%Ca Carbonate None Detected
72.00%Gypsum
8.00%Nan-tihraus(other)
PLM NYS 198.5 VcM NotAnslyzed
FILM NYS 108.6 NOB Not Analyzed
TEM NYS 19SA NOB Not Anaiyzad
Samplell) DW24olnt Compound Description Drywall
062116627.OWS Harries onolty Homogeneous
PLM'NYWIINA Friable 051232021 White 88.00%On Carbonate NOW Detected
4.00%Mica
9.00%Non-ile ous(other)
PLh1 NYS-/tla.a vcm Not Analysed
PLM NYS 1411.6 NOB Nat Analyzed
TEM NYS 198A NOB Not Analysed
Sample ID DW2-Drywall Dase119110n Drywall
062fl6B27-00064 Homogeneity Heterogeneous
-PLM NYS 198.11dable 0912 312 0 21 Brown/Gray 4.00%Cellulose 22.00%Ca Carbonate Nano Detoct d
71.00%Gypsum
3.00%Non-fibrous(other)
PLM NYS 198.6 VGM Nat Anolyzed
PLN NYS 198.6 NOB Not Analyzod
TEM NYS 198.4 NOB Not Analyzed
SamploM KVF1 'Description Vinyl Floor(Kitchen)
062116921-M7 Homogeneity Homogeneous
PLm NYS 198.1 Fiisble Not Analyzed
PLM NYS 188:6 VCNI' Not Analyzed
PLM NYS"1g8:6 NOB 0 8 2 3120 21 Tani White 100.00%Other Inconclusive:None Detected
TEMtNYS 198.4 NOB 0 812 3 2 0 21 Tani White 100.00%Other Now Detected
Samoa to KVF2 Description Vinyl Floor(Kitchen)
062116627.0008 Homogeneity Homogeneous
PLId NYS.198A Friable Not Analyzed
FILM NYS 1S8.G VCM 'NotAwtyzed
PLM NYS ializ NOB 08232021 Tanf White 10D.00%Other InconclUsive:.Now Detected
TEM NYS 198.4 NOB 08232021 Teri White 100.00%Other Nonv Detected
Simple to BVFl Description Vinyl'Floor(Bathroom)
082118827.0009 Homogeneity Heterogeneous
PL81 NYS 108.1 Friable Not Analysed
PLN NYS 198.6 VCbi Not Analysed
PLM,NY&198.6 NOS 0812312021 Gray/While/ 100.00%Other Inconclusive:None Detected
Black
TEM NYS 198A NOB 0B232021 Grayl While! 100.00%Other Now Detected
Black
InlOel roportfrom::0S232021 11:50:41
ASB f08r 0009 0001 Printed 8/23/2a2111:50t50AM Page 2 of 4
ENSLAnalydeal,true. EMSLorder: 06211682T
528 Mineola Avenue Cede Place,NY 11514 Customer ID: TCNS29
TeOFax:(516)907 7251 1(11111)037-7528 Customer PO:
hllpJhvww.EMSL.cem l eadeplacelab®omsi.mm Project ID:
Test Report:Asbestos Analysis of Bulk Matedal
NemAsbeetos
Analyzed
Teat Date Color Fibrous Non-Fibrous Aobiutse
SampWID BVF2 otsaiption Vinyl Floor(Bathroom)
062116827.0010 Homoganstty Homogeneous
PLM NYS 198A Friable NolAnelyaW
PLM NYS 1911AWN! Not Analyzed
PLM NY8188A NOB 08=2021 TOW White 100.00%Other InconolualveoNarle Detected
TEta NY619a.4NC9 08=12021 Taal White 100.00%Other None Dstectod
SamplolD PVF1 Daeer(poon V1nyt F.loor(Poreh)
062116627-0011 Homogeneity Homogeneous
PLM NYS 198.1 Friable Net Analyzed
PLH NYS 198.9 VCM Not Analyzed
PLM NYS'198A N013 08/2312021 Tani White 2.30%Min.Wool 97.70%Other IrtcanWuslas:None Detected
TEM IM 105A NOS 08R312021 Tard'White 100.03%Other Nona Dotaetod
Sample IC PVF2 Description Vinyl Floor(Parch)
052116827-0012 Hamcasnaltv Homogeneous
PLM HYS 10.1 Friable - Not Analyzed
PLdI NYS'198:8 VCM Not Ansiyzed
PLfd NYS'198.a NOB 0812312021 Srowrd White 2.20%Min.Wool 97.80%Other Inconcluslm.,Nona Detected
TEM NYS 198:4 NOB 0812=021 grownt While 100.00RA Other None.Ootocoed
Mini report from:OW21=21 11:50:47
ASt3_198z.0009 6001 Printed 812312021 W50:50AM Page 3 of 4