RC-000323-2016 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: RC-000323-2016 Date Issued: Friday, May 26, 2017
This is to certify that work requested to be done as shown by Permit Number RC-000323-2016
has been completed.
Tax Map Number: 301.13-2-9
Location: 8 PEGGY ANN RD
Owner: Derek Leo
Applicant: Derek Leo
This structure may be occupied as a: Residential Alterations to foundation block
walls;repair and replacement of some cement blocks. By Order of Town Board
TOWN OF QUEENSSBURY
Issuance or Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance,or other issues and conditions as a result of approvals by the
Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development - Building & Codes (518) 761-8256
BUILDING PERMIT
Permit Number: RC-000323-201+6
Tax Map No: 301.13-2-9
Permission is hereby granted to: Derek Leo
For property located at: 8 PEGGY ANN RD
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: Derek Leo Single Family-Alteration $2,500.00
Owner Address: 8 Peggy Ann RD Total Value $2,500.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
Residential Alterations to foundation block walls;repair and replacement of some cement blocks.
$ 60.00 PERMIT FEE PAID -THIS PERMIT EXPIRES: Sunday, May 28, 2017
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before th expiration d e.}
Dated at the Town Quee ury; /�Th une 2,2016
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
PRINCIPAL STRUCTURE APPLICATION Office Use Only
Received
Date: Tax Map ID
Tax Ma ID f. -a Permit No.
Map Permit Fee1��)
Zone Rec Fee
Historic Site Yes No Site Plan#
t?�r �[b� c.G.. u_�. t#Edwelling
Subdivision#SubdivisionName Project Location�� AY 2 8 2015TOWN BD. RESOLUTION 86-2013: $850 recreation fee for newunits single family,;duplexes/two-family
multiple family,apartments, condominiums,townhouses, and/or manufactured & modular homes,'.bdt not mobtl
YRYa
homes. This is in addition to the permit fee(s). 1
Applicant Owner
Address 6 ,1 Address C�
Phone/E-mail Phone/E-mail
Contact Person for Building&Codes Compliance: Jr-C' Phone 36/--ozN-,
TYPE OF CONSTRUCTION
,/Check all that apply New Addition Alteration V floor sf 2°d floor sf Total sf Height
Single Family
'1
Two-Family
Multi-Familyf.y`
(#of units
Townhouse
Business Office
Retail- Mercantile
Factory-Industrial
Attached Garage
(1, 2, 3, 4+)
Other
If commercial or industrial please indicate of business
Town of Queensbury Building& Codes Principal Structure Application Revised September 2015
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Proposed use of building or addition f
Source of Heat(circle one) Gas Propane Solar Other
Fireplace: Complete a separate application for Fuel Burning
Appliances& Chimneys
Are there structures not shown on plot plan? P)o
Are there easements on the property? 9h
Site Information
a. Dimensions or acreage of lot Z46 a5- 1 +
b. Is this a corner lot? V46
c. Will the grade be changed as a result of construction Yes < No
d. Public water or Private well uR�cL
e. Sewer or Private Septic System
Value of all work to be performed(labor or materials) $ Z': o-M
DECLARATION:
1. I acknowledge no construction shall be commenced prior to issuance of a valid permit and will be completed
within a 12 month period.
2. If work is not complete by the 1 year expiration date the permit may be renewed, subject to fees and
department approval.
3. I certify that the application,plans and supporting materials are a true and complete statement/description of
the work proposed,that all work will be performed in accordance with the NYS Building Codes,local building
laws and ordinances,and in conformance with local zoning regulations
4. I acknowledge that prior to occupying the facilities proposed, I or my agents will obtain a certificate of
occupancy.
5. I also understand that I/we are required to provide an as-built survey by a licensed land surveyor of all newly
constructed facilities prior to issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: L"-fF, DATE: `
SIGNATURE: DATE:
For office use only
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
Town of Queensbury Building&Codes Principal Structure Application Revised September 2015
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W.J. ROUR.KE, ASSOCIATES — LICENSED LAND SURVEYORS
299 REWRVO1R ROAD, FORT EDWARD. NEW YORK 12826