application El PRINCIPLE STRUCTURE Office Use Only q
PERM IT IIC, TIr¢N� �n Permit#: C L - v
Town ofQucensbury D r lt�b l� V [j
Permit Fee:$ 1 (0 .J b
742 Bay Road,Queensbury, NY 12804 J JUL 19 2019 *
.../ Rec. Fee: $
P: 518-761-8256 www.queensburynet
TOWN OF QUEENSBURY Invoice#: I 1
BUILDING& CODES
Project Location: 31, A�;w'►'�o,, i2a.a - c51uGt••s /-/', /21 0Y
Tax Map #: 141•ois+/-33 Subdivision Name: A//4
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family, duplexes/two-family,
multiplefamily, apartments,condominiums, townhouses,and/or manufactured & modular homes, but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): LIc c iJ
Mailing Address, C/S/Z: 190 7 #o..).k 9 - Sec., N; /za 2 0
Cell Phone: (S/b' ) 77`f-Eploseit Land Line: (.0)? ) .c!/-/2a/ ex4. '>zi«7
Email: SI Ic.�,
• Primary Owner(s):
Name(s): SL,oe
Mailing Address, C/S/Z: 29o, Roo}e 9- 3j e , ivy /zo?o
Cell Phone: (s/? ) 7 'i- 66,4 y Land Line: (S/s' ) se/-Pao, ex,4. '>zri
Email: SI; P S�c,.k.r•�ssl.�r,
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): S-1-evi r.(s 5t y c CorporGk�vn
Contractor Trade:
Mailing Address, C/S/Z: 240/ 3c.,\\S1,0,, Spc., n/y /a02.0
Cell Phone: (Sea ) 77H-61o0y Land Line: (s-iv ) S '/-/-ao/ eX/. '21)
Email: St cc ,ar.I'i S lei �ssl�o�s.co..�
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: ,cie,n)c,.,-Js gigs Coribr,4-i ,
Contact Name(s): Scoff
Mailing Address, C/S/Z: Pio Ro,pie q- a..146r, Spy., .✓Y/zozo
Cell Phone: ( ' ) Land Line: ( S/t? ) Seri-/2o/ eXl. yz y9
Email: Sic.4,1,,,,r ec4e„h.rJssl.u�t.cow►
Contact Person for Building & Code Compliance:S ee).e.,
Cell Phone: (S/? ) ,7y-6,/pyy Land Line: ( sir? ) sto-izo/ e-,. 'iv7
Email: SI;ce,�ard� f� S�e�,ac,r�ssLaes .Cow,
Principle Structure Packet Revised February 2019
PRO,;ECT INFORMATION:
TYPE: Commercial _ Residential
WORK CLASS:
_Single-Family Two-Family Multi-Family(#of units )
_Townhouse Business Office /Retail Hotel/Motel
_Industrial/Warehouse _Garage(#of cars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: 36 9l0 1ST floor:
2"d floor: 2"d floor:
3rd floor:
Total square feet:
Basement(habitable space):
Total square feet: 3b Fla
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 33-2), o0O
2. Proposed use of the building:Con✓ic.,P.,ec 5-tor self' serve ga.so)s".(
3. If Commercial or Industrial, indicate the name of the business:S,lewkr}s sl„�,s Coro A4ora
4. Source of Heat: Gas Oil Propane Solar Other:Sete C4..:.„ed e1ec rr
(Fireplaces need a separate Fuel Burning Appliances & Chimney Application, one per appliance)
5. Are there any structures not shown on the plot plan? YES 0 Explain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a. What is the dimensions or acreage . e parcel? 1.037 o.cres
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? P BLI PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? p,rrv4e, Se?3',c,
Principle Structure Packet Revised February 2019
DECLARATION:
I. [acknowledge that no construction shall commence priorto issuance of a valid building
permit and work will be completed within a 12 month period.
2. If the work is not completed by the 1year expiration date the permit may be renewed,
subject to fees and department approva I.
3. I certify that the application, plans and supporting materials are a true and complete statement
and/or 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 understand that I/we are required to provide an as-built survey bya licensed land surveyor of
a II newly constructed facilities priorto issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: SC ke,.,
SIGNATURE: a, 46a"4 DATE: 7 / /9
Principle Structure Packet Revised February 2019