application PRINCIPAL STRUCTURE APPLICATION
Office Use Only
Received
Date; Tax Map ID _
Tax Map TD ?� cI [ �Q�, , Permit No. C_c-•0C7p., Zfl
Permit Fee i 2 .ie0
Zone Rec Fee {a
Historic Site yes No Site Plan#
Subdivision Naive �i�E�p � leen Subdivision
TOWN BD. ItES_0LUTION 86-2Q13: $850 RECREATION FEE FOR NEW DWELLING UNITS -SINGLE
FAMILY, DUPLEXESITWO-FAMILY, MULTIPLE FAMILY, APARTMENTS, CONDOMINIMLIMS.
TOWNHOUSES;AND/OR MANUFACTURED&MODULAR HOMES,BUT NOT MOBILE HOMES. THIS
IS TINADDITION TO THE PERMIT FEE.
1 11
Applicant Owner
Address eA;j1 !AD.SjAddress
JUS
P€�onefl✓-maill���R ?�{ PhoneiE-mail
Contact Pet-son for Building&:Codes Compliance: V494t�s -}ALL Phone
TYPE OF CONSTRUCTION
'/Check all that apply Nein Addition Alteration i floor sf 2"`'floor sf Total sf Height
j Single Family +
I
Two-Family e
i I
Multi-Family
(9 of units
i
a
�Tomlnltouse
Business Office j
I
� i
Retail -Mercantile k
f I
Factory-industrial
FAttachedGarage 1
Other
TOWn of Queensbury Building 8-Codes Frincipai Structure Application Revised September 201 l
r ,
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 a
a. Dimensions or acreage of lot :AV
--�0
D. 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 ub
Value of all work to be performed{tabor or materials} $
I.tECLA.RATION.•
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. 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: ��� ..� !1"� :' .r t�"►>� 7`'ar!"��i�'_
SIGNATURE: DATE: AM/. !!
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