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application 4 PRINCIPAL STRUCTURE APPLICATION Office Use Only j Received Date: Tax Map ID Tax Map ID Permit No. Cr—-00034 2 2 ZD b Permit Fee 12499,Zone ` Rec Fee io Historic Site Yes No Site Plan# Subdivision Name AAyy Subdivision# TOWN BD. RESOLUTION 86-2013: $850 RECREATION FEE FOR NEW DWELLING UNITS - SINGLE FAMILY, DUPLEXES/TWO-FAMILY, MULTIPLE FAMILY, APARTMENTS, CONDOMINIMUMS. TOWNHOUSES,AND/OR MANUFACTURED&MODULAR HOMES,BUT NOT MOBILE HOMES. THIS IS IN ADDITION TO THE.PERMIT FEE. Applicant 6ahaewowpw _ Owner Address 66& Jak.{ J�b,GUJTI!� Address PhonelE-mail !Phone/E-mail JU Contact Person for Building&Codes Compliance: rtK•L1 } 44" �. Phone 5�$- TYPE OF CONSTRUCTION ✓Check all that apply New Addition AIteration I'floor sf 21 floor sf Total sf Height Single Family Two-Family Multi-Family (#of units ► ' '! A&i..©11 Townhouse Business Office Retail-Mercantile Factory-Industrial Attached Garage j rr (1, 2, 3, r Other Town of Queensbury Building&Codes Principal Structure Application Devised September 2014 If commercial or industrial please indicate of business Proposed use of building or addition Source of Heat(circle one) _ Oil Propane Solar Other Fireplace: Complete a separate application for Fuel Burning Appliances&Chimneys Are there structures not shown onplot plan? Are there easements on the property? Site Information a. Dimensions or acreage of lot .,.t b. Is this a corner lot? c. Will the grade be changed as a result of construction Yes No d. Public water or Private well e. Sewer or Private Septic System Value of all work to be performed(labor or materials) $ 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 1 year expiration date the permit may be renewed, subject to fees and department approval. 3. I certify that the application,plans and supporting materials are a true and complete statement 1 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 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: ' � !� fir 'Mr, SIGNATURE: DATE: EDDY• For office use oniv 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