application PRINCIPAL STRUCTURE APPLICATION
Office Use OnIN,
Received
Date: rte, Tax Mala ID
Tax Map FD —'�1�� f^/, Permit No.
Perinit Fee _ta
Zone _ Re,Feed upw
Historic Site Yes No I Site Plan#
Subdivision Name " 5ubdivisian#
TOWN BD. RESOLUTION 56-201.3: $850 RECREATION FEE FOR NEW DWELLING UNITS - SINGLE
FAMILY, DUPLEXES/TWO-FAMILY. MULTIPLE FAMILY, APARTMENTS, CONDOM INII`Jl mS.
TOWNHOUSES.AND/OR MANUFACTURED&.MODULAR HOMES,BUT NOT MOBILE HOMES. THIS
IS IN ADDITION TO THE PERMIT FEE.
j Applicant *qA%" Vw. 0toner I
Address 1a412b.S1 rrjE :address
I � I
Phnrte(I✓-mail Phone/E-mail j
i
Contact Person for Building& Codes Compliance: � I 4414W . Phone '0
4 —
j TYPE,OF CONSTRUCTION
-------------------
-`Check all that apply New Addition Alteration Ifloor sf I gild floor sf ��jqToja4f 20 6 Height
Single Family- I
I d -
Two-Family I ==
Multi-Family
(''o;units ` ►l 1 ��/ "� ,� Gi/I-�''
I
Tow-nhouse
{ I
Business Off,Ce
Retail-Mercantile
I
Factoq—-Industrial
I I
Attached Garage
it
�i
Other I -,
Town;of Quocnsbury Building R codes Principal Structure Application Revised September 2014
If commercial or industrial please indicate of business
Proposed use of building or addition
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?
Are there easements on the property?
Site Information 0�
a. Dimensions or acreage of lot ..I`p
b. Is this a corner lot?
C. Will the grade be changed as a result of construction Yes No
C. 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 I 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 NYS Building Codes,local building
Iaws 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: lAgit*
,+�,t.. ..-. �-� �' F�-t %+ 7"�►ir/ 't-� lr
SIGNATURE: DATE: Z/Y 11_- 2K
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