application PRINCIPAL STRUCTURE APPLICATION Office Use Only
Received
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HISTORIC SITE des No
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SUBDIVISION NAME N' Lot�
TIJWN BQ. RESOLUTION 86-2013: $850 RECREATION PEE FOR NEW DWELLING UNITS, INCLUDING SINGLE FAMILY DWELLINGS,
DUPLEXES OR TWO FAMILY DWELLINGS, MULTIPLE FAMILY DWELLINGS, APARTMENTS, CONDOMINIUMS, TOWNHOUSES, AND/OR
MANUFACTURED&MODULAR HOMES, BUT NOT MOBILE HOMES, THIS IS IN ADDITION TO THE PERMIT PEE.
APPLICANT \ r-\ ,1 OWNER � *�� �� C
ADDRESS c A`',J.1 ., ADDRESS
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P'HONEIE-MAIL D3 - ' `vt9 ')1F? PHONE 0 E-MAIL
CONTRACTOR COST OF CONSTRUCTION (ESTIMATED): $
ADDRESS: BUILDING ADDRESS:
PHONEIE-MAIL
CONTACT PERSON FOR BUILDING CODES COMPLIANCE: N 1 -1 , � PHONE
TYPE OF CONSTRUCTION
Check all that apply Please indicate measurements as required below
New Addition Alteration 1't floor sq. ft. 2"d floor sq. ft. Total sq. ft. Height
Single Family
Two-Family
Multi-Family
(# of units )
Townhouse
Business Office
Retail - Mercantile
Factory- Industrial
Attached Garage
(# of J
Other
Towyn of Queensbury Building&Codes � ,. Principal Structure Application July 2014
If commercial or industrial indicate name of business
Proposed use of building or addition rt'31 cie I C�
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?
Are there easements on the property?
Site Information
a. Dimensions or acreage of lot
b. Is this a corner lot? Yl
c. Will the grade be changed as a result of construction Yes No
d. Public water or Private well -M'^7, 1?1,,.,- i k'G
e. Sewer or Private Septic System 491(%"V Jr,,
Value of all work to be performed (labor or materials) $ 200D
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. 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 NY State 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. 1 also understand that 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: DCVW) !�JL1nS.xi DATE'-)- -�
SIGNATURE: r� ._------' DATE -1 -7-0-15
FOR OFFICE USE ONLY
Operating Permit Issued: Yes No
Occupancy Type
Construction Classification
Assembly Occupancy Limit
Special Conditions
2
Town of Queensbury Building&Codes Principal Structure Application July 2014