application PRINCIPLE STRUCTURE
Office Use Only
PERMIT PAtetk rj ;rrnit#:
u V CC- cogs -
Town of Quccnsbury D j $rmit Fee:$ J go I. 3c)
742 Bay Road,Queensbury, NY 12804 MAR 0 4 2020 `Elec. Fee: $
P: 518-761-8256 www.queensburynet
TOWN OF QUEENSBURY Iniroice#: ��S
BUILDING & CODES
Project Location: IZy /1910M
Tax Map #: 3c --tS 504.i4-) -5 Subdivision Name:
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family, duplexes/two-family,
multiplefamily, apartments,condominiums, townhouses,and/or manufactured & modular homes,but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant: \
4
Name(s): QQL (•ems+rwc�-i`a� Sccv.ZK �6G 64_11t.ce ew.. K)
Mailing Address, C/S/Z: 3o/ w�,sh,.. t-n� . v*—. E.A-4.. /rtb/�,. ', ,v, t 2Zo3
Cell Phone: (518 ) z6s--3os 3 Land Line: (C-18 ) 4S .— $Zoo ,. ti243
Email: , ch.A tl( e 8&t. L,c. (.vs,
• Primary Owner(s):
Name(s): The. Sir..fo' W+sei4w/
Mailing Address, C/S/Z: z tt cllNrc,k +cw+ S�r.,,471 A. Spc;..s S / #4'y 1Z8 66
Cell Phone: L ) Land Line: ( St8 ) sec) - zI
Email: k-conalne@ Sar..l-ola CA(-.. orJ
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): ROG (o..s+c..41%1A S.cu;c�S Lt.c.
Contractor Trade: G.e...,+a(
Mailing Address, C/S/Z: 3o1. wv►.tik;As(-eA 404-. E,-+, 11.1e)
Cell Phone: (St8 ) 76s— 30S3 Land Line: (Sit) ) tis'z- eLOd `11-43
Email: n,(A..tc @ ROL. ;..c..( or.
**List all additional contractors on the back of this form
• Architect(s)/Enqineer(s):
Business Name: 40 Ar.k:4•. 4-1, I.
Contact Name(s):
Mailing Address, C/S/Z: 31$1. v�yln...'E.,.� Avg. „r! . Atb,,,� .vy i zzo3
Cell Phone: (S18 ) Z's. 7'ZS Land Line: (Sl8 ) Z to- a 61(4
Email: b na P(.4s:g... L.✓h
Contact Person for Building & Code Compliance: gLv•.M+:... iY•.ss.i vcf�►
Cell Phone: ( '' ) " Land Line: ''( ) ``
Email: "
Principle Structure Packet Revised February 2019
PROJECT INFORMATION:
TYPE: /Commercial Residential
WORK CLASS:
_Single-Family _Two-Family _Multi-Family(#of units )
Townhouse Business Office Retail Hotel/Motel
_Industrial/Warehouse _Garage(#ofcars ) /Other(describe M< 40,1 o4;t)e. Qix;a:..5
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: et9 K) yF 1ST floor: H/
2"d floor: 8 H) sF 2"d floor: --
3rd floor:
Total square feet: /✓ A.
Basement(habitable space): t4)) SF
Total square feet: I° 6)i se
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 3/ .%, oc
2. Proposed use of the building:A4.14....i Se.r�;wn
3. If Commercial or Industrial, indicate the name of the business: 45 t}•sq:4%..( ( Cc,kr
# CAv4cAes4awry
4. Source of Heat•e, Oil Propane 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 Yip Explain:
6. Are there any easements on the property? NO '"1 S �lrw:,• �`/ f�“sa./'t.,�+ A'.+r.,00.1 Ord
7. SITE INFORMATION:
a. What is the dimensions or ay�eage of the parcel? t•t1 o.444 S
b. Is this a corner lot? ES NO
c. Will the grade be changed as a result of the construction? i NO
d. What is the water source? PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Swvc-C
Principle Structure Packet Revised February 2019
DECLARATION:
I. !acknowledge that no construction shall commence priorto 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 approva I.
3. I certify that the application, plans and supporting materials are a true 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-bui It 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: 014.4‘..`I
SIGNATURE: DATE: Z IIAI zvs.c
Principle Structure Packet Revised February 2019