application PRINCIPAL STRUCTURE APPLICATION
Office Use Oniti=
Deceived
Date: I "Tax Map ID
Tax Map ID j _ Permit No- C �CQ bbl b
Permit Fee q 2 fT .b 0
Zone Ree Fee Xk pq n'j- V1
Historic Site Yes No Site Plan 4
Subdivision Name
TOWN BD. RESOLUTION 86-2013: $850 RECREATION PEE FOR NEW DWELLING UNITS -SINGLE
FAMILY, DUPLEXES/TWO-FAMILY, MULTIPLE FAMILY, APARTMENTS, CON-DOMINIMUMS.
TOWNHOUSES,AND/OR MANUFACTURED&MODULAR H09ES,BUT NOT MOBILE HOMES. THIS
IS IN ADDITION TO THE PERMIT FEE.
j ApplicantVfe. Owner �-
Address 856& Jaoe 12b.Sj rrj� Address
Uf
PhonelE-mail Phone/E-mail I
Ir'�cl�� hner�?v eri�Gs. {
Contact Person for Building&Codes Compliance: Vrt�1.�t q 4 4w Phone �l$-
TYPE OF CONSTRUCTION.
i /Check all that apply New Addition � Alteration I,floor sf 2"'floor sf Total sf Height
Single Family
I
Two-Family
i
t"uiulti-Family
(?f of units
a
I Townhouse
Business Office
a' E
1
Retail-Mercantile
i
Factory'-Industrial
Attached Garage
(l, 2, 1�
Other --- i
Tomm o€Queensbury Building&Codes Principal Structure Application Revised September 2014
If commercial or industrial please indicate of business
Proposed use of building or addition
Source of Heat(circle one) ^
Fireplace: Complete a separate application for Fuel Burning Gas Oil Propane Solar Other
Appliances&Chimneys
Are there structures not shown on plot plan?
Are there easements on the property?
Site Information
a. Dimensions or acreage of lot ,..�•0
b. Is this a corner lot?
°• Will the grade be changed as a result of construction Yes No
d. Public water or Private well G
e. Sewer or Private Septic System
Value of all work to be performed(labor or materials) $
ZIECLARATION.
I. 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 I 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 wiI! obtain a certificate of
occupancy.
5. I also understand that I/we are required to provide an as-built survey by a Iicensed 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: ���,���-�.• {,t_. ..— ��2�1T�'i�' � �� t�'�7� 7"a�"t'�►t't;Q/L}�`"'
SIGNATURE: DATE:
For office use only
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
Tour of Queensbury Building&Codes Principal Structure Application Revised Septeinbei 2014