application PRINCIPAL STRUCTURE APPLICATION
Office Use Only
Received
Date: Tax Map ID
Permit No. RC - �j - 2 )i 1 b
Tax Map ID Z�� . I`j - `� Permit Fee I I oo
Zone Ree Fee )rlvo i,-q- 1000
Historic Site _Yes _ No Site Plan 4
Subdivision Name Lot# Subdivision#
Project Location f.r\J4.Ng vt(Le Q a�
TOWN BD. RESOLUTION 86-2013: $850 recreation fee for new dwelling units—single family, duplexes/two-family,
multiple family,apartments,condominiums,townhouses,and/or manufactured &modular homes, but not mobile
homes. This is in addition to the permit fee(s).
Applicant Na
`Z n Owner
Address 544ACU` Address
V g
Phone/E-mail ` Phone/E-mail
14ciZ 3z e)
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Contact Person for Building&Codes Compliance: M tkp, > �l Phone Sl
TYPE OF CONSTRUCTION
,/Check all that apply New Addition Alteration 13'floor sf 21 floor sf Total sf Height
Single Family
F'\A 1 d
Two-Family
Multi-Family f
(#of units )
Townhouse
Business Office
Retail-Mercantile
Factory-Industrial
Attached Garage
(1, 2, 3, 4+)
Other
If commercial or industrial please indicate of business
Town of Queensbury Building&Codes Principal Structure Application Revised September 2015
Proposed use of building or additionIdrR d
Source of Heat(circle one) Gas Oil Propane Solar Other
Fireplace: Complete a separate application for Fuel Burning
Appliances & Chimneys
Are there structures not shown on plot plan? .
Are there easements on the property?
Site Information
a. Dimensions or acreage of lot Yv rp X
b. Is this a corner lot? h�
c. Will the grade be changed as a result of construction _ Yes No
d. Public water or Private well
e. Sewer or Private Septic System Sc$
Value of all work to be performed (labor or materials) $ GtxJ
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. I 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 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 also 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: �,-
PRINTNAME: /\ �I i�-A&L— �b� DATE: �fn�/ /
SIGNATURE: //(hyo DATE:
For office use only
Operating Permit Issued: _Yes —No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
Town of Queensbury Building&Codes Principal Structure Application Revised September 2015