application PRINCIPAL STRUCTURE APPLICATION
Office Use Only
Received
Date: �N�J. ��� Tax Map ID
Tax Map ID ? _� Permit No.
Zone NOV 1it Fee 9099, �,-o
125 �j
MRee Fee -
Historic Site _1 Yes _ No Site Plan#
Subdivision Name ]/uZ Ste+ Subdivision#
TOWN BD. RESOLUTION 86-2013: $850 RECREATION FEE FOR NEW DWELLING UNITS - SINGLE
FAMILY, DUPLEXESi7WO-FAMILY, MULTIPLE FAMILY, APARTMENTS, CONDOMMMUMS.
TOWNHOUSES,AND/OR MANUFACTURED&MODULAR HOMES, BUT NOT MOBILE HOMES. THIS
IS IN ADDITION TO THE PERMIT FEE.
ApplicantOwner
Address Sj� Address
hf �--7,��■`
Phorle/EPhone/E-mail
rican�srinet�er'ho+� er�-i,es.
Contact Person for Building&Codes Compliance: V4Z4N)S1r4 .1-4 LL- AaOA. Phone
lan1 Avg
TYPE OF CONSTRUCTION
✓Check all that apply New Addition Alteration Ir floor sf 2"'floor sf Total sf Height
Single Family
Two-Family
Multi-Family /
(#of units V �l Lil''$/L fh"'71I
Townhouse
Business Office
Retail -Mercantile
Factory-Industrial
Attached Garage
/
(I, 2, 3>`Jr (J `r ���Ztl
Other
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014
If commercial or industrial please indicate of business G,ew1bwt— 5
Proposed use of building or addition QQ,r
Source of Heat(circle one) Gas Oil Propane Solar Other
Fireplace: Complete a separate application for Fuel Burning
Appliances&Chimneys
Are there structures not shown on plot plan? p
Are there easements on the property? Ow
Site Information Not
a. Dimensions or acreage of lot
b. Is this a corner lot? O
C. Will the grade be changed as a result of construction _ Yes No
d. Public water or Private well MAC.
e. Sewer or Private Septic System \1A,rI-a
Value of all work to be performed (labor or materials) $ e2w. 006
DECLARATION.
1. 1 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.
I 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. 1 acknowledge that prior to occupying the facilities proposed, I or my agents will obtain a certificate of
occupancy.
5. 1 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 to the above:
PRINT NAME: ul —
SIGNATURE: DATE: Id Nov 2/4
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 2014