applications PRINCIPLE STRUCTURE Office Use Only
� 1 PERMIT APPLICATI ON
Permit#: -
Town of(Zuccnsbury Permit Fee: $ )IVAt J�
742 Bay Road,Queensbury, NY 12804 *Rec.Rec. Fee: $
P: 518-761-8256 www.queensburynet
Invoice#: M1.0 1
Project Location: I'`Art;461 rl i1 I QY/d Cs-Wes
Tax Map #: r / - / I Subdivision Name: hie Gh/ nd ES-14*e _S
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family, duplexes/two-family,
multiplefamily, apartments,condominiums, townhouses,and/or manufactured &modular homes,but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): \\ 0�1�11�uc�i orb
Mailing Address, C/S/Z: �'� L t2� (e Rao- cQfhiLd5On �a(IS Mis 1.2_3' 9
Cell Phone: ( b I ) cU q- F9Ot/ I Dhi Se Land Line: ( �5�cs') %9F-C 3 , Fic _
Email:CtneSL GL C_V/1, \\AZTe_0 l rLLc on Co • Con--+
• Primary Owners):
Name(s): Mart - S±( e CCL(Lie
Mailing Address, C/S/Z: 4-3 14 (,-nte r2 L--Cth c��€ yrs()u vy
Cell Phone: ( ) Land Line: ( )
Email: i1\cdlr,- c. 1 e. o�v�z \ Cow)
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): + ''Cp
Contractor Trade: E C r O V E 7\
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( I (1 )
Email: i �1 + APR 02 201,9
**List all additional contractors on the back of this form TOWN OF CUEENSBURY
BUILDING&CODES
• Architect(s)/Engineer(s):
Business Name: V1C 1 \5 I ) II a rck e C � e-
Contact Name(s): fkQ cc l
Mailing Address, C/S/Z: 134 IJ ye, 6 (e it). {FcJ((s AN /2 ?43/
Cell Phone: ( ) Land Line: ( 37 , ) /7V/ "��✓ �'
Email: epka II e A/yCOf ° rn, C ova,
Contact Person for Building & Code Compliance: r /Oh re Cell Phone: ( 5/ ) a 7 P.76 V Land Line: (,57k ) 79(p-- z),3,3
Email: ) L°hisr @ S-f-rctcfi 0,n co , Cool
Principle Structure Packet Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Single-Family Two-Family _Multi-Family(#of units )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse cGarage(#ofcars ) _Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
s)
1ST floor: Ft) 1sT floor: 5 la� `� (�a-`/' 4ave
5
2"d floor: 7. 2"d floor:
3rd floor:
Total square feet:
Basement(habitable space):
Total square feet: 3. 0
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ q 03 00 0
2. Proposed use of the building: YThi O
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heagb Oil Propane Solar Other:
(Fireplaces nee. - separate Fuel Burning Appliances&Chimney Application, one per appliance)
5. Are there any structures not shown on the plot plan? YES 7ati'�' Explain:
6. Are there any easements on the property? YES Cr)
7. SITE INFORMATION:
a. What is the dimensions or acreage o the parcel? 4, 501/4 tee. S
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? PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? VLA...1.9V, c -
Princiole Structure Packet Revised February 2019
�
'
` .
^ DECLARATION:
—
1. 1 acknowledge that no construction shall commence priorto issuance of a valid building
penniiand work will be completed within a12 month period.
2. Kthevvork is not completed by the 1yemr expiration date the permit may be manem/ed,
subject to fees anddepartmmntappnova|.
3. | certify that the app|icaUon, plans and supporting materials are a true and complete statement
and/or description of the work propoaed, that all work will be performed in accordance with the
NY8 Building Codes, local building |avva and qndinancea, and in conformance with local zoning
regulations.
4. | acknoxv|adge that prior to occupying the facilities proposed U, ormy agents, will obtain a
certificate ofoccupancy.
5. | understand that |Awe are required txx provide anas-buiIt survey bya licensed land surveyor of
all newly constructed facilities prior to issuance of a certificate of occupancy.
| have read and agree to the above:
PRINT NAME: 01ndy
�|/�/H�TUAE' �� ^ DATE:
__ .. .. -._ __ . - - _ .. -'
Office Use Only
'
y FUEL BURNING APPLIANCE & Permit#: ' H 1 ' • IS)LeiLe,
t `
CHIMNEY APPLICATION Permit Fee:$
Invoice#:
742 Bay Road, Queensbury,NY 12804
P:518-761-8256 www.queensburynet
Project Location: 1.--04q ictkin61-v1C. Tax Map ID: � ? / /6 -
Oreaf-
E.S-t6-Lf e 5
Room of Install: Planned Install Date:
**ONE APPLICATION PER APPLIANCE** f'1lE ��� `�
p;c / d o
CONTACT INFORMATION:
• Applicant:
Name(s): )
Mailing Address, C/S/Z: P o Q R C a.d -�RS> NI� 9 13 y
_(,Cell Ph.: _( ) Land Line: / 1 7'7? 03. �'`
Email: Q rocky �,o I�{-� ���S�tt crti or\Co eow-)
• Primary Owner(s)
Name(s): PO a -c Ska,ce a tr—V Q
Mailing Address, C/S/Z: `k .kun\--Ver Lain e- S �-Q- V1 s bu_ r)
Cell Ph.: _( ) Land Line: _( )
Email: nm cm 6
6 e 9 tv,ai / b C 0 rr -
❑ Check if all work will be performed by homeowner only
• Installer Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): 1 ht Free/a c e (? par >/
Contractor Trade:
Mailing Address, C/S/Z: ? 95/ /Cake e lie ksP Ceor
Cell Phone: _( ) Land Line: _( 5/S' ) Let&?"-9�300
Email:
Contact Person for Building & Code Co pliance: bro, '\ CLef )
Cell Ph.: ) (- w 90 Land Line: ( S`I ) (79F-- 0 3 3
Email: 5S (Do nre OiI\ on,
Principle Structure Packet Revised February 2019
FUEL BURNING APPLIANCE INFORMATION:
• TYPE OF DEVICE:
_Stove _ Fireplace Insert _ Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built**
(**Manufacturer's name: Model #:
SOURCE OF HEAT:
Wood Coal Pellet I Gas
CHIMNEY INFORMATION:
Masonry (require plans to be submitted):
block brick stone
Flue:
_tile steel size, in inches
Material*:
double-wall triple-wall _insulated
(*Manufacturer's name: Model #:
ADDITIONAL INFORMATION:
1. Two inspections are required. A rough-in inspection, prior to installation and a final inspection, after
installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces & chimneys require plans to be submitted.
4. Twenty-four(24) hour notification is required for inspections.
5. Workers' Comp insurance information is required with this application.
Declaration:Construction/installation must conform to NYS Fire Prevention &Building Code and/or manufacturer
requirements. The applicant or owner agrees to comply with all applicable laws, ordinances, regulations and all conditions
that are part of these requirements and also will allow the inspector to enter the premises to perform the required
inspections.
I have read and agree to the above: L
PRINT NAME: a Indy S + Alkfe C=kl ( 1-411 -A-F',-12) )
SIGNATURE: DATE: `a �< /
Principle Structure Packet Revised February 2019