application ? 1
PRINCIPAL STRUCTURE APPLICATION r
Office Use Univ
Received
Date: I Tax Map ID
r4 I Permit No.
Tax Map
Pen-nil Fee Ck ZL°l0t•bo
Zone !
Rec Fee 92�4
Historic Site Yes No Site Plan#
Subdivision NaTne Subdivision#
TOWN BD. RESOLUTION 86-2013: $850 RECREATION FEE FOR NEW DWELLING Ti ITS - SINGLE
FAMILY, DUPLEXES/TWO-FAMILY, MULTIPLE FAMILY, APARTMENTS, CONDOM1NJIVIUMS7
TOWNHOUSES,AND/OR MANUFACTURED&c MODULAR HOMES,BUT NOT MOBILE HOMES. THIS
IS IN ADDITION TO THE PERMIT FEE.
Applicant � Owner
Address 0446(G eA;j1 12b,Sj Address
!
PhanefE-mail Phone/E-mail s }
Contact Person far Building&Codes Com pliatce: l � ! A Phone'
TYPE or CONSTRUCTION
ION i
✓Check all that apply New Addition Alteration 1,floor sf 2"`'floor sf Total sf Heicr
ght
Single Family
1
i Two-Family
Multi-Family1 Y i
(#of units_e' I ►I Iti
! Townhouse
i
Business Office l
Retail-Mercantile
Factory-Industrial
I
Attached Garage
(l, 2. 3_
Other
!
Tow':of Queensbury 13uilding&Codes Principal Structure Application Revised September 2014
If commercial or industrial please indicate of business
Proposed use of building or addition
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? D
Are there easements on the property? Noka
Site Information
a. Dimensions or acreage of lot
b. Is this a corner lot? G
C. Will the grade be changed as a result of construction yes No
G. Public water or Private well fit•{L
e. Sewer or Private Septic System SAM
Value of all work to be performed(labor or materials) $
17ECLARATION.
1. 1 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 I year expiration date the permit may be renewed, subject to fees and
department approval.
3. 1 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 newl
constructed facilities prior to issuance of a certificate of occupancy. y
I have read and agree to the above:
PRINTNAME: JWt
Maw,*
�,,.
SIGNATURE: DATE: 1v�fr• ��'
For office use oniv
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
To%%m of Queensbury Building&Codes Principal Structure Application Revised September 2014