application Permit No. Dog Sr 1/0
Building&Codes Office-Department of Community Development-Town of Queensbury Fee Paid 13S. 3(,
742 Bay Road,Queensbury,NY 12804 Recreation Fee
Dave Hatin,Director codes@aueensbury.net
Phone: (518) 761-8256 FAX: (518) 745-4437
Principal Structure Building Permit Application
Application & Plans sub1ect to review before issuance of a valid permit for construction.
Instructions: A permit must be obtained before beginning construction. No inspections will be made until the
applicant has received a valid building permit. All applicants' spaces on this application must be completed and
must appear on the application form.
Applicant/Builder O.K C Not-0,`A)6 S) mA.Ay C( 7 wner: 0 kC Hot a'N4 S/LA4-t7 CC vie
Address: 13 0 '9 ' N Address:
Home Phone: C S t Q ) 7 9 3 - 7 2 22 Home Phone:
Email Address: Email Address:
Cell Phone: 3 6 / - 2 $ 3 6 Cell Phone:
FAX Phone: FAX Phone:
Person responsible for supervision of work with respect to building and codes compliance:
Name: C. L L 7 e E.- 12/1 S tS
Address: 1 3 O#9 IA)ti hO QveeNs/S,,.Ly, • i /2 $'py Phone 793- 7277
Location of proposed construction: Lot No. Legal Address:
Tax Map Number: 3 0 $'• ! - 1 _ 1 7 Subdivision Name: N / e
Estimated Cost of Construction: $3 0O4 OOJ FQ . /o c'N ;TS VET
"
Proposed construction is for: Residential Use X Commercial Use A[�DECEN
Name of Business: L v z e A 1`o,q/) S 7,, 2. 1 2f305
If proposed construction is an addition, what will use of new addition be? TOWN OF G pis COD Y
13k W— 1�'Nam----
New Addition Alteration Proposed Construction 10 Floor 2^d floor Other Total Proposed
structure (Occupancy Type) Sq. Ft. sq.It. Sq. Ft. Square feet Height
Ft.S.in.
Single-Family Dwelling •
Two-Family Dwelling
Townhouse
Multifamily Dwelling
Number of Units:
Office
Mercantile
Manufacturing
/D St&j S7�.14ft 13LDG5 Other: 20'X /35- _ 2,700sq rr K 10 /3L-D6.S 27,000 sQ F1 as
Attached Garage 1, 2, 3 19t
Qi,06
Type of Heating System: Electric, Oil, Gas, Wood, Forced Hot Air, Baseboard, Other: N o IV e
If a fireplace and/or woodstove are being installed, please refer to a separate application. N/ /9
Applications are subject to Zoning Administrator, Code Compliance, and Structural Plan review.
The Building and Codes Office will allow commencement of your proposed project only after
issuance of your permit.
Declaration: Please sign below after you have carefully read the statement:
To the best of my knowledge, the statements contained in the application, together with the plans and
specifications submitted, are a true and complete statement of all proposed work to be done on the described
premises and that all provisions of the Building Codes, the Zoning Ordinance, and all other laws pertaining to the
proposed work shall be complied with, whether specified or noted, and that such work is authorized by the owner.
Further, it is understood that I/we shall submit prior to a Certificate of Occupancy or Certificate of Compliance
being issued, as requested by the Zoning Administrator or Director of Building and Codes, an As-Built Survey by a
'icensed surveyor, drawn to scale, showing actual location of all new construction.
Date: Applicant/Builder Signature:
the application of dated is hereby approved and
permission granted for the construction, reconstruction or alteration of a building/and or accessory structure as set
orth above.
Date: Authorized Signature:
:\Sue Hemingway\Building.Permit.FORMS\Principal Structure Permit Application.doc V:12/14/04