application ij
--+--?`/„i L ^ / +J � O Office Use Only
f � �, Permit#: /L- .7 9- C) /g
APPLICATION Permit Fee:$ C1, 4,
742 Bay Road,Queensbury, NV 12804 *Rec. Fee:$ lc,
P: 518-761-8256 wwv/ .qu.e n s[pry nei Invoice#: (U 7-2
Project Location: S2 N e,V 11,4qTrc.v.X1t ui
Tax Map #: 2 Z 7.)D- I -Lz- r&78 Subdivision Name:
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single-family,dup+e ' ,
multiplefamily, apartments,condominiums, townhouses,and/or manufactuiad & mbdulat'htsj?bufln\/ i b'i
homes. This is in addition to the permit fee(s). i r
CONTACT INFORMATION: [ j NOV 2 6 18 :J
• Applicant: TO'.;ViNI OF 0 NSBURY
k '' ` r �� -1 DEVELOPMEN1
Name(s): -1 o.�c\L gas 04(-Gat t
Mailing Address, C/S/Z: i'- c .rry t 2.4 iVozrli CQ2etc N.Y. 1Ztfs3
Cell Ph.: _( 5 t g ) 7 41-1-t'ct s Land Line: ( s!8 ) 2 si -3 4.l f
Email: Mc-Cott . 14 Q a°orie 4 ry T. Ner
• Primary Owner(s): /( o„-en.,ger ,,)018- a_
Name(s): ReltIN `( "To.-► cEnAD --ijWroe.K (re CeJ tM
Mailing Address, C/S/Z: 1- o x5bolp, ' S - Fi., .13q i �a ' � .
Cell Ph.: - -e `'``La_(54t ) 3�7 -oz.zs nd Llne: _(1/t ) 43t- 1307
Email:
• Contractor(s):
Name(s): MC CA i► Co wsTeoc.Ttow
Mailing Address, C/S/Z: N S Gc,)rv+.3i 2g il)oL-fhCeee IA NY ties-3
Cell Ph.: _( S)B ) 74L4 - /K is Land Line: _(51 b ) zs-1- 3b t Y.
Email: )'Ltc. C4 t{ . k e r'bNTie(l,roei.ce r
• Architect(s)/Engineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Ph.: _( ) Land Line: _( )
Email:
Contact Person for Building & Code Compliance: -.. ,oexuAc MC CM t
Cell Ph6/B( 7y 4t ) t t-0 R s Land Line: _( 578 ) 241 -36 f et
Email: ► c CA-1 c . K a Vaoo+i eIL .Ayer
ToQ Building&Code Enforcement Principle Structure Revised March 2018
PROJECT INFORMATION:
TYPE: Commercial Residential L� � � ie,5 OA,/ L�
WORK CLASS:
Single Family Two-Family Multi-Family(#of )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#ofcars ) Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: 6 7 2- PT floor:
2nd floor: "'--` 2nd floor:
3rd floor: Total square feet:
Basement(habitable space):
Total square feet: (0 7 7.
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 1}30.000 ou O
2. Proposed use of the building: l;0as-t- irchArt
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one): Gas Oil Cropanj 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 xplain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? 6 2.3 3 I .$ s7 Fee.r 1. to Ages
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 CFRIVAT_D WELL
e. Is the parcel on l .WER r a PRIVATE SEPTIC system?
ToQ Building&Code Enforcement Principle Structure Revised March 2018
DECLARATION:
I. I acknowledge that no construction shall commence prior to 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 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-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: Boas (I/1CCAI •
SIGNATURE: DATE: I I- 24- 1 a
ToQ Building&Code Enforcement Principle Structure Revised March 2018