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DEMO-0646-2023 Office Use Only DEMOLITION APPLICATION Permit#: - Ott b-2Q2.3 Permit Fee:$ (1OrJ Town of Queensbury Invoice#: 2- 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Flood Zone? Y N Reviewed Demolition Location: \2 JZXrl NV-U Tax Map ID#: **AN 4 E 'Q I R Q L D i OL TION A PLICA IO BMIS O S** DEMOLITION INFORMATION:1. Where will demolition material be disposed? .. ;1'` ri k \1 2. Type of structure to be demolished: a. Residence_ d. Storage Building b. Garage e. Other: 1-71) c. Business I © LEpVi In' 3. What type of utilities are connected to the structure:: '4"I a. Gas f. Well-Water Pump OCT 1 ' 2023 b. Fuel Oil g. Public Sewer TOWN OF QUEENSBURY c. Propane h. Other BUILDING&CODES d. Electric i/ i. None e. Public Water 4. Have ALL utilities (water, electric, etc.) been disconnected? Yes t/ 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. 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: Y MK. SIGNATURE: 9„ DATE: 101111207 Demolition Application Revised June 2022 0 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): Qspc )( L \o r�-h9 Mailing Address, C/S/Z� 1/V,c 'r 4 \c .9 N 1 " Cell Phone: Land Line: 1 �(o24 Email: • Primary Owner(s): Name(s): xVYUL C-S c v&J 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: 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: - w\ cank' Cell Phone: Land Line: Email: Demolition Application Revised June 2022 TOWN OF QUE,.i'MS..J " FILE COPY A .. Reviewed By: > , 41, Date: D ifi l� e c El 1 1120: E ii II ��TOVV1Y OF QUEENSBURY ,o-Azr� 1� y BUI DING& CODES I Cr`tr`.y`7'r51 I0}'L:t SLF� - N!J ry I ' ...,,-.-7 1 11 . , • s \\111 r tiCgrgX ON Kart ur / iw wmc ` i 'f ___________—_,,-_--_..--.--.----4 _____—) \I iv I f rF.-, CIP.l i I mar.r„.....4,_:jr. '')i rt.., 2-,Qtr. \ \ 111 'f ' ruf.7,it\ _____\ \II . \ I `P \ es,w.�sasi�ffi. 'd it 1i ' \ II 1 i. __,_\ \ tat 1 ro -' \T ti V r - ti � I\ \‘. Ins r . 302.19-1-30 DEMO-0646-2023 Langworthy, Roger 54 Western Ave Demolition of in-ground pool