application Permit No. cQx1S 1L S'
Building&Codes Office-Department of Community Development-Town of Queensbury Fee Paid ) 35. °b
742 Bay Road,Queensbury,NY 12804 Recreation Fee
Dave Hatin,Director codes@aueensburv.net I L
Phone: (518) 761-8256 FAX: (518) 745-4437
Principal Structure Building Permit Application
Application & Plans subject to review before issuance of a valid permit for construction.
Instructions: A permit must be obtained before beginning construction. No inspections will be made until the
applicant has received a valid building permit. All applicants' spaces on this application must be completed and
must appear on the application form.
Applicant/Builder O-K C a LO,` 6 S J 1,mA.,y et-v%wner: D kC HoL a'NG S,Login7 CL,,T€
Address: 1 3 0 A w Ni \Z O Address:
Q ve s (3,. 1y , 1zg09
Home Phone: (S ? 4 ) 7 9 3 - 7a 2 7 Home Phone:
Email Address: Email Address:
Cell Phone: 3 6 / - 2 9 3 6 Cell Phone:
FAX Phone: FAX Phone:
Person responsible for supervision of work with respect to building and codes compliance:
Name: C 4 L,Te E i74-1 (In .S es
Address: 13 0Aw�� hO Qvez•�r/S .L /V•`j• /2 $'oy Phone 793 - 7277
Location of proposed construction: Lot No. Legal Address:
Tax Map Number: 3 0 8"• 1) - 1 / 7 Subdivision Name: N / i9
Estimated Cost of Construction: $3 0 0, 0 of F,,L f o v
Proposed construction is for: _Residential Use X Commercial Use 31d3
Name of Business: L, v z e A_ e_ C- a, ) SN7e-
If proposed construction is an addition,what will use of new addition be?
New Addition Alteration Proposed Construction la Floor 2^d floor Other Total Proposed
structure (Occupancy Type) Sq.Ft. sq.ff. Sq.Ft. Square feet Height
Ft.S In.
Single-Family Dwelling
Two-Family Dwelling
Townhouse
Multifamily Dwelling
Number of Units:
Office
Mercantile
Manufacturing
/0 SeLP 57v,1044_ aL065 Other: Z01)( 135 r Z,70os4 P7 X /0 /3c-D6S ,2Z000 So 1t DP
Attached Garage 1, 2, 3
a.06
Type of Heating System: Electric, Oil, Gas, Wood, Forced Hot Air, Baseboard, Other: N o (V e
If a fireplace and/or woodstove are being installed, please refer to a separate application. A)/ /9
Applications are subject to Zoning Administrator, Code Compliance, and Structural Plan review.
The Building and Codes Office will allow commencement of your proposed project only after
issuance of your permit.
Declaration: Please sign below after you have carefully read the statement:
To the best of my knowledge, the statements contained in the application, together with the plans and
specifications submitted, are a true and complete statement of all proposed work to be done on the described
premises and that all provisions of the Building Codes, the Zoning Ordinance, and all other laws pertaining to the
proposed work shall be complied with,whether specified or noted, and that such work is authorized by the owner.
Further, it is understood that I/we shall submit prior to a Certificate of Occupancy or Certificate of Compliance
being issued, as requested by the Zoning Administrator or Director of Building and Codes, an As-Built Survey by a
'icensed surveyor, drawn to scale, showing actual location of all new construction.
Date: Applicant/Builder Signature:
[he application of dated is hereby approved and
Permission granted for the construction, reconstruction or alteration of a building/and or accessory structure as set
orth above.
Date: Authorized Signature:
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