applications w
PRINCIPAL STRUCTURE APPLICATION Office Use Only j5:,q V I& 2-3®/
DATE /6 / 7,1l-7 Received
TAX MAP ID
Pe e �(�'I w_7 0
ZONING I OCT U 4 2 l R 4 Y Sb . uo
Si #
HISTORIC SITE Yes /NoTOWN OF QUEEN,% i0vis n #
HISTORIC SITE Yes No BUILDING&COES
SUBDIVISION NAME ` Lot#
TOWN BD,RESOLUTION 86 2013: $850 RECREATION FEE FOR NEW DWELLING UNITS,INCLUDING SINGLE FAMILY DWELLINGS,DUPLEXE
OR TWO FAMILY DWELLINGS, MULTIPLE FAMILY DWELLINGS, APARTMENTS, CONDOMINIUMS, TOWNHOUSES, AND/OR MANUFACTURED i
MODULAR HOMES,BUT NOT MOBILE HOMES. THIS IS IN ADDITION TO THE PERMIT FEE.
APPLICANT � 141 OWNER
r�ADDRESS �� ADDRESS
�ct'�
PHONE/E-MAIL �/ ?lJ/—z7wz,-- PHONE/E-MAIL
CONTRACTOR COST OF CONSTRUCTION(ESTIMATED): $ UADDRESS: ��/V i/ BUILDING ADDRESS: `7 Z f"11'V 14/0"410.
PHONE/E-MAIL
CONTACT PERSON FOR BUILDING& CODES COMPLIANCE: �f1 PHONE
TYPE OF CONSTRUCTION
Check all that apply Please indicate measurements as required below
New Addition Alteration 1 st floor sq. ft. 2nd floor sq.ft. Total sq.ft. Height
Single Family
Two-Family
Multi-Family
(# of units )
Townhouse
Business Office
Retail - Mercantile
Factory- Industrial
Attached Garage /
Other
Town of Queensbury Building&Codes Principal Structure Application July 2014
w
If commercial or industrial indicate name of business '
Proposed use of building or addition
Source of heat (circle one) Ga� Oil Propane Solar Other
Fireplace: complete a separate application for Fuel Burning Appliances &
Chimneys
Are there structures not shown on plot plan?
Are there easements on the property?
Site Information
a. Dimensions or acreage of lot /?e r )rf7�� /
b. Is this a corner lot? Al j
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) $T, eQ Q DECLARATION-
1. I acknowledge no construction shall be commenced prior to issuance of a valid permit and will be completes
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 departmer
approval.
3. 1 certify that the application, plans and supporting materials are a true and complete statement/ description c
the work proposed,that all work will be performed in accordance with the NY State Building Codes, local buildini,
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 /we are required to provide an as-built survey by a licensed land surveyor of all newt,
constructed facilities prior to issuance of a certificate of occupancy.
I have read and agree to the above: PRINT NAME: �D �LXZ.E'Mif__- DATE
SIGNATURE: ,ll C - DATE /a Z// 7
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 July 2014
Town of Queensbury Thomas R. Van Ness
Highway Department Highway Superintendent
742 Bay Road, Queensbury, NY 12804 Home: (518) 745-0929
Phone: (518) 761-8211
Fax: (518)745-4466 David Duell
Deputy Highway Superintendent
Home: (518) 745-0938
DRIVEWAY PERMIT
Date: ra z-17.
Applicant Name: Z L
Telephone No.: 7i,
Address to Be Inspected: i
Return Address: I<F9 ��
4
Applicant must show exact location and width of driveway(s) to be connected to the highway t
placing stakes at the specified location.
The Superintendent of Highways of the Town of Queensbury has reviewed this application. Tl-
following action has been taken:
STEP 1: ( ) Preliminary approval
NEED ( ) Slight Swale
( ) Deep Swale
( ) Level with the road
( ) Level with the top of the paved wing
Size culvert pipe to be used (if necessary)
( ) 12" ( ) 15" ( ) 18" ( )24' ( )36'
Preliminary inspection completed by: Date:
Approval by Highway Supt.: (or) Deputy Supt.:
Upon completion please resubmit this approval permit for a final approval.
STEP 2: ( ) Final Approval ( ) Rejected
Date:
Thomas R. Van Ness, Highway Superintendent David Duell, Deputy Highway Superintendent
Town of Queensbury Building&Codes Principal Structure Application July 2014
Fuel Burning Appliance & Chimney Application Office use Only
Received
DATE: 10171-7 Tax Map ID
TAX MAP ID: Permit No.
Permit Fee
ZONE:
OWNER Z-e4A,
�L����i p -� I PHONE/E-MAIL
ADDRESS
INSTALLER/ PHONE/E-MAIL
BUILDER /; ! !T'-C- �
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE:
PHONE/E-MAIL BUILDING ADDRESS
ROOM OF INSTALL: _l��? /.1hti PLANNED INSTALL DATE:
r �
FUEL BURNING APPLIANCE INFORMATION WOOD COAL PELLET GAS OIL NOTE: ROUGH-IN&
STOVE FINAL INSPECTION ARE
FIREPLACE INSERT REQUIRED.
FIREPLACE,FACTORY BUILT* NOTE:
MANUFACTURER'S
FIREPLACE,MASONRY INSTALLATION MANUAL
FURNACE(GARAGE ONLY) MUST BE AVAILABLE AT
TIME OF INSPECTION
*If factory built provide manufacturer name: 1c� �/ ; Model
Listed by: Number:
CHIMNEY INFORMATION
Masonry** (check one) BLOCK BRICK STONE
Flue TIE STEEL Size in inches
Material DOUBLE WALL _TRIPLE WALL INSULATED
** If non-masonry provide manufacturer name: Model#:
DECLARATION: Construction/installation must conform to NYS Fire Prevention & Building Code and/or
manufacturer requirements. The applicant or owner agrees to comply with all applicable laws, ordinances,
regulations,and all conditions that are part of these requirements and also will allow inspector's to enter premises
to perform required inspections.
I HAVE READ AND AGREE TO THE ABOVE:
PRINT NAME: fi/0 (� ��� DATE: ,ll�A
i i C
SIGNATURE: ^_ DATE:
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014