2002-303 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 128M902 (518)761-8201
Community Development-Building&Codes (518)761.8256
ERTIF1 LI"� CE
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Permit Number. P20020303 Date Issued: Thursday,May 16,2002
This is to cer*that work requested to be.done as shown by Permit Number P2.0020303
has been completed.
Tax Map Number. 523400-290-000-0001-066-000-0000
Location: 21'BROOKFIELD Run
Owner. ANTHONY&JAMIE METIVIER
Applicant: ANTHONY&JAMIE METIVIER
This structure may be occupied as a;
By Order of Town Board . .
Shed I Storage Sheds TOWN OF QUEENSBURY
Director of Building&Code Enforcement
Building Permit Application
Town of Queensbury—Dept of Community Development,742 Bay Road,Queensbury,NY
(518)761-8256
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A permit must be obtained before begirming construction. Permit File No. _ - -
No inspection will be made until applicant has received a Fee Paid $
valid building permit. All applicants' spaces on this Rec.Fee Paid $
application must be completed and must appear on the Reviewed By-
application form.
Applicant__�, .�ur��� Owner:
Address: Address:
Phone#( ) - Phone
Property Location: Lot Number: I House Number
Subdivision Name: Tax Map Number:
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o New Building: residence /commercial Estimated`Markefvalue of Construction:$
❑ Addition: residence/ commercial
❑ If an Addition,what will use of new addition-be? '
'Alteration: residence/ commercial ?
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❑ No change to exterior size nce/com'l
9� 'Other work(describe t� )
Check OccupancyInformation 1"Floor 2n Floor Other floor Total
Feet Iuare
Below sq.ft. sq.ft. sq.ft. Square f!
❑ Single family dwelling
❑ Two family dwelling
❑ Townhouse APD
❑ Multifamily.dwelling ti
#of units ®® �Op
❑ Office
❑ Mercantile
❑ Manufacturing
❑ 1 car detached garage
❑ 2 car detached garage
❑ 3 car detached garage
❑ 1 car attached garage
❑ 2 car attached garage
❑ 3 car attached garage
❑ Storage building-
commercial S
Storage building-
residential
❑ Other
What is the proposed height of the structure_ feet (3 inches
Will any second-hand or ungraded lumber be used? If so,for what? )10
Type of Heating System: electric/ oil / gas/wood /forced hot air/ baseboard/other: /Y-,
Number of Fireplaces to be installed ND Number of Woodstoves to be installed /Y� ✓�
List below the person(s)responsible for supervision of work as regards to building codes:
Name Address Phone Number
Builder
Plumber
Mason
Electrician
Declaration: please sign below after you have carefully read the statement:
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To the best of my knowledge the statements contained in this 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.Code,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 licensed surveyor;drawn to scale,showing-actual
location of all new construction.
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Signature �..�• - owner,owner's agent,architect,contractor
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UA7EU ULCLM13LH /, 196/
LAST REVISED JUNE 7, 1988
BY VAN DUSEN & STEVES
LAND SURVEYORS
303
('moo _ -- �,,,�e �' s
z LOT is PR 2 3 2002
TOWN OF OUG.E.N6BURY
•�'j.Oe\ F I.��I linir�Aran rOr)E
LOT 21 \ \
2.63 ACRES
PROPANE \ \
TANK
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WELL � Q I HEREBY CERTIFY THAT THN
FROM AN ACTUAL Fl
THIS TIFlCATION SH
(� FOR WHOM THE SuR.
AND LENDINCCERVIFIc
INSTIIUTI,.
LOT 23
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