application _...,....Offi e Use Only
Town of Queensbury Buildinlr-CoOs i t,---;. 0 \\y
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PRINCIPAL STRUCTURE ilki NCANN2 8 2014 el it No.: h.;
A permit must be obtained before bag( rig construction Per it Fee: $ `16) )-
‘.
.. TOWN OF QUEENSBUF y*Rec Fee.
_ $
Please read: *TB resolution 86-2013(1-28-2013): $ 50 recreCibil Itelfdaav didellAS '
units, including single-family dwellings,duplexes or niLiffipeamly y —Si e Ian No.:
dwellings, apartments, condominiums, townhouses, and/or manufactured and modular Subdivision No.:
homes,but not including mobile homes. This is in addition to the permit fee.
, ,• '
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Date - I - I 14 Applicant 1-11-12_ 141D t-L-C
Tax Map ID Address Liqz_ Ccerz_m\ \ 1.2-ok
Zoning Qi,._,2„tr,N.0.3tin LIN( )7:‹0-1
Phone/E-mail
Property Owner 12... HD 1-1-C. Contractor/Agent RD 4,1
Address LI 14 2- ecTe-IAN P-d Address 4-1L Cdevr\-1711 12_01
z.fr,kuo,rus1\ 1,1\1 ra6q Gkaft. 1-iN,1 1-z-tv-i
Phone/E-mail (5(8_) 2-(e0-(4V-0 Phone/E-mail Stl',. 21.o 0-&-IZ‘O
Building Street Address: 1414 Z eCY19-A1 V-C) q-G10," iy/Z-aY:/
Subdivision Name: , Lot#: Historic Site: Yes No
Estimated cost of construction: $ 2/60 0
op+-Zia,
Type of Construction:
Check all that apply Please indicate measurements as required below:
c =
_
0 0 -
:...
.4_-. . 1st Floor 2nd Floor Other Total Height
.7 < 7,i-
Single Family ,
. .
Two-Family
Multi-Family(#of
units" )
•
Townhouse
, /,,,,s
Business Office .
• ' 1-7,nii-'.
Retail-Mercantile
Factory-Industrial
Attached Garages(# )
Other
Town of Queensbury Building&Codes Principal Structure Packet 518-761-8256
1
1
If commercial or industrial indicate name,of business Z. RD
Proposed use of building or addition
%-t—eflOC
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I 'Source of heat(circle one) G as Oil Propan Solar Other
a _ t
Fireplace-complete a separate application for"Fuel Burning Appliances&Chimneys" _Yes No
Are there structures not shown on plot plan? 0
Are their easements on the property?
Site Information
. I
a. Dimensions or acreage of lot �� S
b. Is this a corner lot? ,AJO
c. Will the grade be changed as a result of construction: _Yes INo
d. Public water or Private well 60/1
e. Sewer or Private Septic System ,
Value of all work to be performed(labor and materials) $
s i
° Declaration: I acknowledge no construction activities shall be commenced prior to issuance of a valid permit and will be completed
within a 12 month period. If work is not complete by the 1 year expiration date the permit may be renewed, subject to fees and
department approval. I certify that the application, plans,and supporting materials are a true and complete statement/description of the
-work,proposed,thatrall;work will be performed.in accordance with the NY State Building
Codes, local building laws and ordinances, and
in conformance with local zoning
regulations. I acknowledge that prior to occupying.the facilities proposed, I or my agents will obtain a
certificate of occupancy. I also understand that I/we are required to provide an as-built survey by a licensed land surveyor of all newly
constructed facilities prior : 'ssuance of a certificate of occupancy,.
I have read an' ••reeto a above.
Signed 1 Date: 5-1
w
FOR OFFICE USE • LY:
Operating Permit Issued: _Yes _No
Occupancy Type: ,
Construction Classification:
Assembly Occupancy Limit: �f
Special Conditions:
Town of Queensbury Building&Codes Principal Structure Packet 518-761-8256
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