application PRINCIPAL STRUCTURE APPLICATION Office Use Only
DATE —� " Received
- Tax Map ID
TAX MAP/D _ V 'ermit No. /O
t C ermit Fee 500 OO cad
ZONING tR ni; I ",ec Fee
11 Ar 2 U 2UW to Plan #
HISTORIC SITE Yes .� Subdivision #
TOWN OF QUE CODES
SUBDIVISION NAME WW1 of#��
TOWN BD_RESOLUTION 86-2013: $850 RECREATION FEE FOR NEW DWELLING UNITS,INCLUDING SINGLE FAMILY DWELLINGS,DUPLEXES
OR TWO FAMILY DWELLINGS, MULTIPLE FAMILY DWELLINGS, APARTMENTS, CONDOMINIUMS, TOWNHOUSES, AND/OR MANUFACTURED &
MODULAR HOMES, BUT NOT MOBILE HOMES. THIS IS IN ADDITION TO THE PERMIT FEE.
RIO o�.rJ (Df7(E�N)- ,U:), - Ems\
APPLICANT O Elm ASC I.� N� OWNER (ROBEFT GR111�1�i� FVU J
ADDRESS Uk)EE") 1% ) 5 ADDRESS 5 PA WD\A Q�\J
Ns4 1 Z -\ tib 177N
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PHONE/E-MAIL 7C:6— C(pci7 PHONE/E-MAIL -1 C‘ f D EID-1 Ftp, -143-4104)
Re io W J
ONT ACTO - — : COST OF CONSTRUCTION(ESTIM�A^TED): $ Oct„1
ADDRESS: BUILDING ADDRESS: \_D C-1 14 c
PHONE/E-MAIL 1_,0_: (1D
CONTACT PERSON FOR BUILDING& CODES COMPLIANCE: O R 1 A tx)PtAj t�gi oZt. PHONE
TYPE OF CONSTRUCTION
Check all that apply Please indicate measurements as required below
New Addition Alteration 1st floor sq. ft. 2"d floor sq.ft. Total sq. ft. Height
Single Family
Two-Family
Multi-Family FkRC
(# of units ) \ `• ( ,if
Townhouse
Business Office
Retail - Mercantile
Robert Gardens North BP 2015-102
Factory Industrial Building 140, Apartment 5
Attached Garage Fire Restoration 117 sq. ft.
(# of )
residential alteration
Other
1
Town of Queensbury Building&Codes Principal Structure Application July 2014
If commercial or industrial indicate name of business
Proposed use of building or addition k Al___
Source of heat (circle one) Gas Oil Propane Sola-Other
Fireplace: complete a separate application for Fuel Burning Appliances &
Chimneys
Are there structures not shown on plot plan?
Are there easements on the property?
Site Information
a. Dimensions or acreage of lot
b. Is this a corner lot?
c. Will the grade be changed as a result of construction Yes No
d. Public water or Private well
e. Sewer or Private Septic System
Value of all work to be performed (labor or materials) $
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 NY State 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 to the NAME: 7c-•issuaance of a certificate of occupancy. /
I have read and agreeabov#PRINT4�` '`h`` � DATE t/ l9
i'c cc�i
SIGNATURE: L,-'j DATE V �� 5
FOR OFFICE USE ONLY
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
2
Town of Queensbury Building&Codes Principal Structure Application July 2014