application PRINCIPLE STRUCTURE Office Use Only
y ' PERMIT APPLICATION
Permit#: CC, —DZ211 2-0\1
Town ofQyeensbty Permit Fee: $
742 Bay Road,Queensbury, NY 12804 *Rec. Fee: $ oS\Pr
P: 518-761-8256 www.queensbury.net ����
Invoice#:
AVO..W IL"Project Location: k441—
Tax Map #: 2- t.^ \-5° Subdivision Name:
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): LE i 2(it' 11
Mailing Address, C/S/Z: (vZ . r(�'�'2 `,L,t Pttt �-�
Cell Phone: (Sc-t ) ?4 --22&-c-k Land Line: ( fr) 7' 2 ^ t3-) (
Email:
• Primary Owner(s): CEillrg
Mailing Address, C/S/Z: AP
Cell Phone: ( ) Land Line: j
Email: O u�1r�9'
a& CCDg--S
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): PALE- FZ /)t..rtit✓ X
Contractor Trade:
Mailing Address, C/S/Z: to2A 6c-ccr avati F/ t 5 FL; A)-' P- t 12 0 I
Cell Phone: (S16s ) 2 -'-( Land Line: (5t ) -?et 2 -- t 1
Email:
**List all additional contractors on the back of this form
• Architect(s)/Enqineer(s):
Business Name: pt (ij5k f,t-v�
Contact Name(s): krW 4\E c-
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line:
Email:
Principle Structure Packet Revised February 2019
PROJECT INFORMATION:
1
TYPE: kommercial Residential
WORK CLASS:
Single-Family Two-Family Multi-Family(#of units )
Townhouse Business Office Retail Hotel/Motel
Industrial/Warehouse Garage(#of cars ) kOther(describe .?---tszit'Attii1Y1
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1ST floor: 4 1ST floor:
2nd floor: '3 2nd floor:
3rd floor:
Total square feet:
Basement(habitable space):
Total square feet: a55,12
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ `"C DO f tW O. 47)
2. Proposed use of the building: ' 9 L�'Z '-
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat: Gas Oil 3r-Opa—n-e Solar Other:
(Fireplaces need a separate Fuel Burning Appliances &Chimney Application, one per appliance)
5. Are there any structures not shown on the plot plan? YES NO Explain:
6. Are there any easements on the property? YES g)
7. SITE INFORMATION:
a. What is the dimensions or a eage of the parcel? 10
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the constr 2 AO NO
d. What is the water source? PUBLIC PRIVAT WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? eel 1
Principle Structure Packet Revised February 2019
.0 4,
DECLARATION:
I. !acknowledge that no construction shall commence prior to issuance of a valid building
permit and work will be completed within a 12 month period.
2. If the work is not completed by the 1year expiration date the permit may be renewed,
subject to fees and department approva I.
3. I certify that the application, plans and supporting materials are a true 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 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:
PRINT NAME: •
SIGNATURE: DATE: If— /9-19
Princinle Structure Packet Revised February 2019