application PRINCIPAL STRUCTURE APPLICATION
Office Use Only
Received
Dale: ! Tax Map ID I
Tax Map ID S02._CL Permit No. CC• � �l�
Permit'Fee `} �1G.Z tq •t�}
Zone
tec Fee `4
Historic Site Yes No Site Plan#
Subdivision Name lAwn=—umaw Subdivision#
TOWN BD. RESOLUTION 86-2013: $850 RECREATION EEE FOR NEW DWELLING UNITS - SINGLE
FAMILY, DUPLEXES/TWO-FAMILY, MULTIPLE FANULY, APARTMENTS, CONDOMINIIgUMS.
TOWNHOUSES,AND/OR MANUFACTURED&MODULAR HOMES;PUT NOT MOBILE HOMES. THIS
IS IN ADDITION TO THE PERMIT FEE.
j
Applicant Owner
Address eA;T 1AD.1W n2Address
f
Phone/E-rrtasl �U` � � Phone/E-rnail
7l �
�`se1r'�nerfo>nr1 ergs. ,t-
Contact Person for Building&:Codes Cornplianee: Pwullll� 4414 Phone
TYPE OF CONSTRUCTION P
(Check all that apply ?vein Addition Alteration I'floor sf 1 2" floor sf Total sf I Height
Single Family '
I
e
Two-Family
Multi-Family # i t
i (#of units '�� � �
Townhouse i
Business Office
I
Retail -Mercantile
Factors,'-Industrial 1
I
Attached Garage
it
Other u
Town of Queensbury Building 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
I Fireplace: Complete a separate application for Fuel Burning
Appliances&Chimneys
I Are there structures not shown on plot plan?
Are there easements on the property?
Site Information
a. Dimensions or acreage of lot — ---��
b. Is this a corner lot? >y?
c. Will the grade be changed as a result of construction Yes No
d. Public water or Private well G
e. Sewer or Private Septic system
Value of all work to be performed(labor or materials} $ +y
DECLARATION.
1. I 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.
J. I 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. 1 acknowledge that prior to occupying the facilities proposed, I or my agents will obtain a certificate of
occupancy.
5. I also understand that I J 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: � ilJt�.- •,�. 1 .�- Mr-,
SIGNATURH: DATE.
For office use only
Operating permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
Town of Queensbury.Building&Codes Principal Structure Application Revised September 2014