application fOffice Use Only
*k_K. QV\ CC-pip 1 '2Q i�'j
PERM1 Permit#: -
APPLICATION
Permit Fee: $
742 Bay Road,Queensbury, NV 12804 *Rec. Fee:$ N Ar
P: 518-761-8256 Invoice#:
Project Location: (,e "f3 Uprc G ter, Si-.
Tax Map #: Subdivision Name:
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). ---
ptCEDVE
CONTACT INFORMATION:
• Applicant: DEC 21 2018kJ)
Name(s): I4 ll pro Res-fr,( -rve• CLrd mar, Strutn TOWN OF QuE=' °ZY
1 BUILDINC&
Mailing Address, C/S/Z: ,�s .. Scr74-cy. (1.ol &nSevcwel- N11 Dl dGG&..
Cell Ph.: _( ) Land Line: (sits ) 743-5311
Email: \i;c�i� tQ c. ' err:h.e(p.uf.+ (er,A aitern help. .otb e a..itiore hel�.c -•.
• Primary Owner(s):
•
Name(s): mac,Lrt 's
Mailing Address, C/S/Z: ( ti 3 'upper 6 itiN S{ _ Q,,•ee ry r,:K,/ IvY la-FCo
Cell Ph.: _(5 t ' ) `t ito Land Line: (5-I- ) iy 3 -567G
Email: J J6_.r.ribs @ ce.114 We. Ray 0 qJJ . e .
• Contractor(s):
Name(s): 19-iIpro R -h,r 4 l2.e'tenst{ustiun 1r1UYtn2. icfs
Mailing Address, C/S/Z: 135): S6 4-6 A-1 Rd. Ivy i ae3 I Sr,.4-6-4-03,,.a9ve_
Cell Ph.: _( ) Land Line: _(SM. ) 7 3- 3'.311 , .S I -`x2 -y ced
Email: 3iy A 6-Li 6-Li pro help ion Oer� f? t it pro help .rcr rd 14-i1fr.heir,car+-.
• Architect(s)/Engineer(s):
Name(s): (a4 rrtp r_ V s en -k& K
Mailing Address, C/S/Z: $ Fretekr3 St. G ITA\; ►a_cls /J`l I L OI
Cell Ph.: _( ) Land Line: _( ) 4 t5 - oeoi
Email: .9./5c.3,e .ors 3 R_ yc,hoo.ror,
Contact Person for Building & Code Compliance: ._ K'� N 3 ' 1t)
Cell Ph.: Land Line: _( Prto
Email:
ToC!Building&Code Enforcement Principle Structure Revised March 2018
PROJLCT INFORMATION:
TYPE: � Commercial Residential
WORK CLASS:
Single-Family - Two-Family Multi-Family(#of )
Townhouse Business Office ,Zetail Hotel/Motel
Industrial/Warehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: Xq 3 , q(, 1ST floor:
2"d floor: 2nd floor:
3rd floor: • Total square feet:
Basement(habitable space):
Total square feet: 3-ci 3.
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ # l � `{ 57.55
2. Proposed use of the building:
3. If Commercial or Industrial, indicate the name of the business: fir`s;clSQ
4. Source of Heat (circle one): Gas Oil Propane Solar Other:
(Fireplaces need a separate Fuel Burning Appliances& Chimney Application, one per appliance)
5. Are there any structures not shown on the plot plan? YES NO Explain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel?
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? PUBLIC PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system?
ToQ Building&Code Enforcement Principle Structure Revised March?n1R
DECLARATION:
I. lacknowledgethat no construction shall commence prior to issuance ofavalid building
perm and work will be completed within a 12 month period.
2. If the work is not completed 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 t rue 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-bui It 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: Set].-n-7,I\ 1.10c-j I-0-
SIGNATURE: c> DATE: J)./11/I
ToQ Building&Code Enforcement Principle Structure Revised March 2018