applications PRINCIPAL STRUCTURE APPLICATION Office UseOniv NC _2M„-ZCfD
DATE F( J I ��t4 Received v X014
Tax Map ID
TAX MAP ID '� Permit No. j
Permit Fee �—
P
ZONING Rec Fee 9 S
Site Plan#
HISTORIC SITE Yes I' �I fNo Subdivision#
SUBDIVISION NAME !�l(1/' /'. !IL/ Lot#
TOWN BD.RESOLUTION 86-2013.�h��$$8Tb0'RECREATION FEE FOR NEW DWELLING UNITS,INCLUDING SINGLE FAMILY DWELLINGS,DUPLEXES
OR TWO FAMILY DWELLINGS, MULTIPLE FAMILY DWELLINGS, APARTMENTS, CONDOMINIUMS, TOWNHOUSES, AND/OR MANUFACTURED &
MODULAR HOMES,BUT NOT MOBILE HOMES. THIS IS IN ADDITION TO THE PERMIT FEE.
APPLICANT �/t/`I,f�L�.t,lLj OWNER QA(l isA00,
ADDRESS ADDRESS � l //6e d �M+n er '/P /
/[ � //
PHONE/E-MAIL �gqPsQe/lQ IiL�'!(JI1 , CMPHONE/E-MAIL
CONTRACTOR COST_I L_ g�r�('� C� COST OF CONSTRUCTION(ESIIMATED): $,/L
ADDRESS: !=1 CnIVO^ PA �t. p(: BUILDING ADDRESS. r��-. erdl /tU
0�v las%5
PHONE/E-MAIL �J
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE'
TYPE OF CONSTRUCTION
Check all that apply Please indicate measurements as required below
New Addition Alteration V floor sq.ft. 2nd floor sq.ft. Total sq.It. Height
Single Family41 b
Two-Family
Multi-Family
(# of units_)
Townhouse
Business Office
Retail- Mercantile
Factory- Industrial
Attached Garage
(# of l x 4I 5
Other
1
Town of Queensbury Building&Codes Principal Structure Application July 2014
If commercial or industrial indicate name of business
Proposed use of building or addition
Source of heat(circle one) Gas Oil ropan Solar Other
Fireplace: complete a separate application for Fuel Burning Appliances &
Chimneys
Are there structures not shown on plot plan? WQ
Are there easements on the property? Q
Site Information
a. Dimensions or acreage of lot j
b. Is this a comer lot?
c. Will the grade be changed as a result 9f construction Yes No
d. Public water or Matee. Sewer or Private Value of all work to be perfmaterials) s
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 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 NY State 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 1 /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: /f�p e�L DATE
SIGNATURE: 116 DATE
Jy
v
FOR oFmce USE ONLY
Operating Permit Issued: —Yes _No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
2
Town of Queensbury Building&Codes Principal Structure Application July 2014
Office Use Only
FUEL BURNING APPLICANCE &
Received
CHIMNEY APPLICATION I Tax Map ID
(� I Permit No. / <4"4 S7,
DATE ® I I Permit Fee
TAX MAP ID
ZONING
OWNER: �t— PHONE/E-MAILj" `_ ' V
ADDRESS ���*�TT���`C")/CUU)
INSTALLERIBUIL AA� >gV f r%< PHONE/E-MAIL
ADDRESS:
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: PHONE
BUILDING ADDRESS:
Fuel Burning Appliance Information WoodCoal Pellet Gas Oil NOTE: ROUGH-IN & FINAL
Stove INSPECTIONS ARE REQUIRED.
Fireplace Insert
Fireplace, Factory built'
Fireplace, Masonry
Furnace(Garage Only)
"If Factory built provide manufacturer name #(C-A ; model#:
Listed by: Number:
Chimney Information
Masonry" (check one) _Block _Brick _Stone
Flue Tie feel _Size in inches
Material Double wall Triple wall _Insulated Av
Direct Vent Chimney Liner
""If Non-masonry provide manufacturer name: model#:
DECLARATION: Construction/Installation must conform to NYS Fre Prevention & Building Code and/or manufacturer
requirements. The applicant or owner agrees to comply with all applicable laws, ordinances, regulations, and all
conditions that are part of these requirements and also will allow inspector's to enter premises to perform required
inspections.
I have read and agree to the above: Print Name: r IS c Date:'� 6l r
Signature: / Date:
s
Town of Queensbury Building&Codes Principal Structure Application July 2014
Town of Queensbury c' S Thomas R. Van Ness
Highway Department I 4 Highway Superintendent
742 Bay Road, Queensbury, NY 12804 Home: (518) 745-0929
Phone: (518)761-8211
Fax: (518)745-4466 David Duell
Deputy Highway Superintendent
Home: (518)745-0938
DRIVEWAY ERRMIT
Date:
Applicant Name:
Telephone No.:
Address to Be Inspected: 6
Return Address:
Applicant must show exact location and width of driveway(s) to be connected to the highway by
placing stakes at the specified location.
The Superintendent of Highways of the Town of Queensbury has reviewed this application. The
following action has been taken:
STEP 1: ( ) Preliminary approval
NEED ( ) Slight Swale
( ) Deep Swale
( Level with the road
( ) Level with the top of the paved wing
Size culvert pipe to be used (if necessary)
( ) 12" ( ) 15' ( ) 18" ( )24" ( )36"
Preliminary inspection completed by: Date:
Approval by Highway Supt.: (or) Deputy Supt.:
Upon completion please resubmit this approval permit for a final approval.
STEP 2: ( ) Final Approval ( ) Rejected
Date:
Thomas R. Van Ness, Highway Superintendent David Duell, Deputy Highway Superintendent
7
Town of Queensbury Building& Codes Principal Structure Application July 2014