application �(�anD FEF_
' PRINCIPAL STRUCTURE APPLICATION
Office Use Only Z 0l rj- Zo
�~ Received
Date: Tax Map ID
Tax Map ID �- Z�� DEC lPnpV40.
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Zone -.- Rec Fee
Historic Site _Yes No Site Plan#
Subdivision Name Lot# Subdivision#
Project Location Qj 0 pA \4UtAi �CHn fILL -
TOWN BD. RESOLUTION 86-2013: $850 recreation fee for new dwelling units—single family,duplexes/two-family,
multiple family,apartments,condominiums,townhouses,and/or manufactured&modular homes, but not mobile
homes. This is in addition to the permit fee(s).
Applicant t�6wgq
Owner 1 .T �/
Address Address C�
Phone/E-mail Phone/E-mail
Contact Person for Building&Codes Compliance: DC)00 J AN Phone
TYPE OF CONSTRUCTION
,/Check all that apply New Addition Alteration I'floor sf 21 floor sf Total sf Height
Single Family
Two-Family x
Multi-Family
(#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
Proposed use of building or addition F
Source of Heat(circle one) Gas Oil C12EMJe Solar Other
Fireplace: Complete a separate application for Fuel Burning
Appliances &Chimneys
Are there structures not shown on plot plan? OeE 59AAJX_�tJ�
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. 1 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 t the above:
�RINT NAME: DATE: Z D "
.*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