application Office Use Only
t�i:e_ l___ Permit#: RC.—Z`�-O� ` 4 8
HERMIT
-t
APPLICATION
Permit Fee: $
742 Bay Road. Queensbury, NV 12804 *Rec. Fee: $
P 518-761-8256 Invoice#: 2-1
Project Location: 197 45SL Mi L ' Poin gOA-D
Tax Map #: Qv Aa.C, i 9 — a , a. Subdivision Name: A-4,-1Y poior i 4 ry
TOWN BD.RESOLUTION 86-2013 $850 recreation fee for new dwelling units leu _ ,. o family,
multiple family. apartments condominiums townhouses,and or manufa tarteu h�n obithomes. This is in addition to the permit fee(s). lV
CONTACT INFORMATION: NOV 0 9 2018
• Applicant: TOE OF gUEENSBURY
Name(s): C. Z,4 r v :� v�5 t satin i NG BUILDING&CODES
Mailing Address, C/S/Z: yS9) L KESFfa/LE •Pr2 i.�o-ro•v 4-4-Ni,,t Ivy zgy�
Cell Ph.: _( 5 l8 ) 'LEo s3 y Land Line: _(s 8 ) C y y- 7o y6
Email:0hn s's c c c-s
• Primary Owner(s):
Name(s): ii . F,z: t Lo,z24-live c:Itz KOGnidill
Mailing Address, C/S/Z: . ,�� . �.aK� �� , ,.NY ,Zc(y_S'
Cell Ph.: i( ) Land Line: _( )
Email:
• Contractor(s):
Name(s): 6- ;-?s
Mailing Address, C/SIZ:
Cell Ph.: ( ) Land Line: _( )
Email:
• Architect(s)/Endineer(s):
Name(s):
Mailing Address, CIS/Z:
Cell Ph.: ( ) Land Line: ( )
Email:
- G .R D- sn -ti3d-' f
Contact Person for Building & Code Compliance: T0i1/11 .S - G r2iq;n1P.y4_ O-4v S
Cell Ph.: _( $i5 ) ?6c - 366 y Land Line: _(5-7P ) -20,4
Email: 4-614a ,(eau cr�t, ,•.vnl ck s , L.c -
Tn(1 Ruildinv&Cede Fnfnrrement Prinrinle Structure Reviced March 201 R
PROJECT INFORMATION:
TYPE: Commercial '� Residential
WORK CLASS:
Single-Family Two-Family _Multi-Family(#of units
Townhouse Business Office Retail
Industrial/Warehouse Garage (#of cars ) _Other (describe
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: b
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ .100 , 000
2. If Commercial project, what is the proposed use: ?X.S
3. Source of Heat (circle one): Oil Propane Solar Other
Fireplaces need a separate Fuel Burning Appliances&Chimney Application
4. Are there any structures not shown on the plot plan? YES �NO�Explain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? _ 5Z6L()r
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? PUBLIC PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Svc
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
r r
DECLARATION:
I. I acknowledge that no construction shall commence priorto issuance of a valid building
perm 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 approval.
3. I certify that the application, plans and supporting materials are a t rue 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 Ikve 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: Jot.-1 ry (!1919�s
SIGNATURE: DATE: lot ,L l f�
To()Buildine&Code Enforcement Prinrinla Sin.rt,ra Rnvicari Marrh 701 R