application PRINCIPLE STRUCTURE Office Use Only
PERMIT APPLICATI ON Permit#:
Town of Queensbury Permit Fee:$ 1218 CJ 1)0
742 Bay Road, Queensbury, NY 12804 �ll, *Rec. Fee:$ tll A,
P: 518-761-8256 www.queensbury.net
Invoice#:
Project Location: 4 oil ,- d 1
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Tax Map #: ?0Z — �,, 'I " ZL ,AU ivision Name: ? J ' S rta're
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family, duplexes/two-family,
multiplefamily, apartments, condominiums, town houses,and/or manufactured & modular home obile
homes. This is in addition to the permit fee(s). E
CONTACT INFORMATION: D
• Applicant: AU
G 17 2020
Name(s): rO n e TOWN OF QUEENSBURY
Mailing Address, C/S/Z: FTU
Cell Phone: 1 2 Z9 :�I71 . Land Line:
Email:
Primary Owner(s):
Mailing Address, C/S/Z: ZG goolfuc--�
Cell Phone:�_) Land Line:
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp document tion must be submitted with this application
Contractor Name ) (' y Name(s): '16
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line: �)
Email:
"List all additional contractors on the back of this form
• Arch itect(sVEngineer(s):
Business-Name: a +' _.�V1
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:�)
Email: C-7
Contact Person for Building & Code Compliance: ,'rw �h I <Si 1V7Q1 e-
Cell Phone: i'F ) -7;?!2—7 q77 Land Line:
Email: GeYr<zy-y ,.Mgy& • ('Q
Principle Structure Packet Revised February 2019
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• Contractorls): Workers'Comp documentation must be submitted with this application
Contractor Name(s): Ci Tiu ea
Contractor Trade: �. .44
Mailing Address, C/S/Z:
Cell Phone: _) ) m !' Land Line: . �L ) `�� 1,2491
Email:_ ` (VA- 0-ri n C, 0= P401 ' r01/1
• Contract orls): Workers'Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade: <
Mailing Address, C/S/Z:
Cell Phone: _(,15'1 0 .31-Land Line: -5jZj
Email: W by Sr -beApto 9-1 L#. a �ea�e�9
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• Contractorls): Workers'Comp documentation must be submitted with this aRROcation
Contractor Name(s): 01%'p v, `�, - Inm 4
Contractor Trade: d`f� iv .. �o�►
Mailing Address,C/S/Z: p
Cell Phone: ) -2 w2 = Land Line: ) W
Email: .r
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• Contractor(s): Workers' ocumentation must be submitted with this application
Contractor Name(s): v fG111I/1b 14 v * 1 e- Msg
Contractor Trade:
Mailing Address, C/S/Z: Adi T S '2�y1
Cell Phone: ) Land line:
Email: Cp-n j cE-to,l 'ecla
• Contractor(s): Workers"Comp documentation must be submitted with this application
Contractor Name(s): UZ
Contractor Trade: e C r-
Mailing Address, C/S/Z; ��• - ed C_�- tt
Cell Phone: - " Land Line: . ( )
Email: e A f
�• Contractor(s):Workers' Comp documentation must be submitted With this application
Contractor-Na-me(s):
Contractor Trade:
Mailing Address, C/S/Z:_ �_ . c � g e'A
Cell Phone: qIqI Land Line: ,A„_)
e.b, �nla trrur3ure Packet Revised February 2019
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PROJECT tNIF—DRMATION:
TYPE: Commercial Residential
WORK CLASS:
_Single-Family —Two-Family _Multi-Family(#of units )
Townhouse Business Office Retail Hotel/Motel
gndustrial/Ware house _Garage(#of cars ) — Other(describe )
STRUCTURE SQUARE FOOfT_AGE: GARAGE SQUARE FOOTAGE:
1ST floor: (vC9 o (Y 00 = 3l I'U� 1ST floor:
2nd floor: 2nd floor:
3rd floor:
Total square feet:
Basement(habitable space):
Total square feet: (a c>c7
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$
2. Proposed use of the building:
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat: Gas Oil Propane Solar Other:
(Fireplaces need a separate Fuel Burning Appliances&Chimney Application, one per appliance)
5. Are there any structures not shown on the plot plan? YES NO Explain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:
a.What is the dimensions or acreage of the parcel?
b. Is this a corner lot? . YES NO
c.Will the grade be changed as a result of the construction? YES NO
d. What is the water source? PUBLIC PRIVATE WELL
• e. Is the parcel on SEWER or a PRIVATE SEPTIC system?
Principle Structure Packet _ Revised February 2019
DECLARATION:
I. 1 acknowledge that no construction shall commence priorto issuance of a valid building
permit and work will be completed within a 12 month period.
2. If the work is not completed by the 1year 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
and/or 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. 1 understand that Me are required to provide an as-built survey by a licensed land surveyor of
all newly constructed facilities priorto issuance of certificate of occupancy.
I have read and agree to the above:
PRINT NAME: (C44�.�
SIGNATURE: f----�-�J^ DATE: /
Principle structure Packet Revised February 2019