application TOWN OF QUEENSBURY jam` REVIEWED BY: -
COMMUNITY DEVELOPMENT DEPARTMENT 'ww�
BUILDING & CODE ENFORCEMENT f FEE PAID: i
531 BAY ROAD
QUEENSBURY, NEW YORK 12804 PERMIT NO. 7310
(518) 745-4447
BUILDING PERMIT APPLICATION
A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION. NO INSPECTIONS
WILL BE MADE UNTIL APPLICANT HAS RECEIVED A VALID BUILDING PERMIT.
All applicants ' spaces on this application MUST be completed and the
signature of the applicant MUST appear on the application form.
OWNER OF PROPERTY: U 5?n L- 3e cke r ,
Mailing Address : FOIL i Bc)( 5c1 Call St Lake Luz-rne .Jy' i2-S4(o
Telephone Number(s) : Work 18-7{o l y2 ) Hdme .51 g 4,5 9- 2.'o7 Other 5/E 79.2.
T he-/n; �
PROPERTY LOCATION: ✓(e4M L eke , queensbvey . )"Y / 2-gc)`f
Tax Map Number: Section Sl Block Lot li
Subdivision Name: Lot No.
NATURE OF PROPOSED WORK: ESTIMATED MARKET VALUE OFFHE
CONSTRUCTION: $
NEW BUILDING:
RESIDENCE/COMMERCIAL OCCUPANCY INFORMATION:
ADDITION TO BUILDING: PRI ARY BUILDING -
/ RESIDENCE/COMMERCIAL V Single Family Dwelling
\/ ALTERATION TO BUILDING: Two Family Dwelling
RESIDENCE/COMMERCIAL Family Dwelling
(NO CHANGE TO EXTERIOR SIZE) Office
OTHER WORK (DESCRIBE BELOW) Mercantile
Warehouse
Manufacturing
Other
GROSS AREA OF PROPOSED STRUCTURE:
1ST FLOOR 5 .25 SQ. FT.
IF ADDITION, USE OF NEW ADDITION:
2ND FLOOR SQ. FT.
OTHER FLOORS SQ. FT.
(not unfinished cellar or basement) ACCESSORY BUILDINGS :
Detached Garage - One/Two Car
TOTAL FLOOR AREA: ,53o;2c SQ. FT. Attached Garage - One/Two Car
Private Storage Building
SIZE OF NEW STRUCTURE: Commercial Storage Building
Other ft/C/J
FEET X FEET
Foundation Type: P1CQe S (cET6311.4) Will any second-hand or ungraded
Number of Stories : / lumber be used? If so, for what?
(habitable space only) ii P/4( 1)0
Height (grade to ridge) :r feet Type of Heating System:
Number of fireplaces and/or woodstove (circle all which applies )
to be installed: E Electric / Oil / Gas / Wood
Forced Hot Air / Baseboard / Other
PERSON RESPONS6g1A51FJR� P, RVISION OF WORK AS REGARDS TO BUILDING CODES IS:
Al
NAME OF BUILDER/ADDRESS/PHONE: �/ f' // 24' Z7,QP 61( % S I" -lq2,
NAME OF PLUMBER/ADDRESS/PHONE:
NAME OF MASON/ADDRESS/PHONE : ����NAME OF ELECTRICAN/ADDRESS/PHONE: `9 �
07
DECLARATION
To the best of my knowledge the statements contained in this appli-
cation, 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 Code, 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, an AS BUILT PLOT PLAN
drawn to scale, showing actual location of oject on em es ..
Signature y L- , €C 1--(-(- ____--
(Owner, owner' s agent, architect, contractor)
FOR ANY SPECIAL PROVISIONS - SEE REVERSE SIDE: