2012-442 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: P20120442 Application Number: A20120442
Tax Map No: 523400-302-008-0001-010-000-0000
Permission is hereby granted to: MTM LLC
For property located at: 319 BAY Rd
in the Town of Queensbury,to construct or place
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Tyke of Construction Value
Owner Address: MTM LLC Sign
C/O CONVENIENT MEDICAL Total Value
319 BAY Rd
QUEENSBURY,NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
CARSON SIGNS
518-321-6179
1053 STATE RTE 9
OUEENSBURY NY 12804-0000
Plans&Specifications
2012-442
Sign Permit 50 sq ft
CONVENIENT MEDICAL CENTER
$150.00 PERMIT FEE PAID-THIS PERMIT EXPIRES:
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town of Queensbury; Wednesday,October 03,2012
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
•
OFFICE USE ONLY • ••
30 v�,b- /-/4ERMIT NO. `e)'`' I�ERMIT F /k(. {a `� ,
TAX MAP NO. � � �
APPROVALS: DEPOSIT f
,
SIGN PERMIT APPLICATION:
A permit must be obtained before installation of your permanent sign. All applicants'spaces on this application must
be completed and
must appear on the application form.
�/I
OWNER: t ' LLC INSTALLER/B ILDE I vi ,-
I I
ADDRESS:C.f 1 eni,Lyeni ekt 6tAeSced are,3f R f /AD( RESS .' YLr//A y (02�7)S -
PHONE NOS. 5(O '"02_/O / PHONE NOS. e1 r, !�/ - (p I' q / ,)/ /
LOCATION OF PROPOSED INSTALLATION:(LEGAL ADDRESS) 31q�I c.'3 1 pd, /f�(,(��-IF3F. , l7�/ 1t)9 f.
BUSINESS COMPLEX/PLAZA/MALL NAME: CJ)11 Qer]i t /SVA Pd)(- '9 ( c k J J
BUSINESS NAME: C6}'11,1'1 II° Ul//4 L (_e -'
CONTACT PERSON FOR SIGN CODE COMPLIANCE: ""1 e V Vi 1 I A%PHONE: 5 I e 7-92 -_2/v X C
TYPE OF SIGN PROPOSED: /freestanding _wall awning projecting
IF SIGN IS TO BE ILLUMINATED,PLEASE INDICATE: _Internal /External _Incandescent _Neon _Other
DO SIGNS CURRENTLY EXIST ON THE PROPERTY? "Yes No
IF YES,LIST ALL EXISTING SIGNAGE: l(r Pi V,a,(4i161.4 0 Irl br1 d. (A)w 1/ / L ii
( �..nd 1'' K i 4- �.
The application creates a change S to ` N
in the following existing site Change in number of signs from to
conditions(fill in all applicable Change in setback for sign from_ to
spaces): Change in size of sign from to
Change in height of sign from to
Change of wording/copy from: to:
Sign Wording/Copy:
Sign size: Length.`) x Width /() =Total Sq.ft. C)C) SignHeight(freestanding sign): /r
Color and Material to be used: t,,O r(,i .s t -1,,-. 6')(j/1-I- P A)t`4h folk_ a..f 1Cl Pyuilo
✓ Provide 2 copies of a scaled drawing or surveyed plot plan with the following information:
o Location of sign(walls signs: drawing of the facade
the sign will be located on,indicate sign on facade)
o Height of freestanding sign QUESTIONS? CALL 761-8256 OR EMAIL
o Depth of projecting sign codes(a)queensbury.net
o Distances from front and side property lines. VISIT OUR WEBSITE FOR MORE INFORMATION
✓ Provide 2 drawings or photos of sign design. www.queensbury.net
I Provide Applicant and Owner's signature(permission
for placement of sign on the property or building).
Declaration: 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 Zoning Ordir}a ce,and all other laws pertaining to the proposed work shall be complied with,whether
specified or noted,and that such •rk is authorized by the owner.
r
APPLICANT SIGNATURE: _ ' i DATE: 1 0
I hereby authorize the applicant o pre. sign on my • perty or building.
OWNER SIGNATURE: / /1 A /_ DATE: (--r7 1 d r
Town of Queensbury• Community Development Office• 742 Bay Road, Queensbury, NY 12804
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