VILLAGE OF BALLSTON SPA			DATE APPLICATION MADE_____________
 BUILDING DEPARTMENT			PERMIT NO.___________________________
 APPLICATION FOR				ISSUED_______________________________
 BUILDING PERMIT 				EXPIRES______________________________

ALL CONSTRUCTION TO BE IN COMPLIANCE WITH "NEW  YORK STATE UNIFORM FIRE PREVENTION AND BUILDING CODE" AND "VILLAGE OF BALLSTON SPA ZONING ORDINANCE."___________________

1	GENERAL INFORMATION
 PDD/Subdivision Name ____________________________________
         Tax Map No.  ____________/_________________/______________
         Ownership:  Private_____________________ Public_____________

2      APPLICANT 
         Name___________________________  Position________________________ Organization________________
         Address   ____________________________  City________________________ State_______ Zip Code_______
         Telephone No.  (         )___________________________                       Ext. ___________

3      PROPERTY OWNER 
         Name_______________________________  Position_____________________ Organization________________
         Address__________________________________  City_____________________ State______ Zip Code_______
         Telephone No.  (         )___________________________                       Ext. ___________
                                                      
4       PROPOSED CONSTRUCTION LOCATION 
         Street No. _____________________             Street Name ____________________________________________ 
        Apartment No. __________________            Zoning District __________________________________________ 

5       USE 
         Existing Use ____________________________________ Proposed Use ________________________________ 
 
6      TYPE OF WORK 
        New _____________   Addition ____________  Alteration _________________ Change of Tenant____________ 
        Other_____________ 

7      PROPOSED BUILDING 
        Height ____________                Actual Stories __________             Total Size____________square feet 
        Type of Frame ____________   Type of Foundation _____________ No.  of  Rooms(exclude bathrooms)______
        No. of Bathrooms _______ No. of Bedrooms ______Primary Heating System________Type of Fuel ________                 
        Sprinklers _________   No. of Fireplaces _________ No. of Wood Stoves _____ Central Air Conditioning ______         
        Style _______________________________Garage:  Attached __ No. of Cars ___ Unattached __ No. of cars____
 
8      ARCHITECT/ENGINEER 
        Name ____________________________________  Position ____________________  Organization __________
        Address__________________________________  City_____________________ State______ Zip Code_______
        Telephone No.(         )_________________Ext. _______ Professional License No. ______________State_______
 
9      CONTRACTOR 
       Name ____________________________________  Position ____________________  Organization __________
       Address__________________________________  City_____________________ State______ Zip Code_______
       Telephone No. (____)_____________  Ext. _________  Liability Carrier ______________Policy No. _________

10	NAMES, ADDRESSES AND TELEPHONE NOS. OF SUBCONTRACTORS

           

11     COST AND FEES 
         Estimated Cost $__________________        Building Permit Fee $  _________________________
12     PROVIDED WITH THIS APPLICATION 
        Two (2) Complete Sets of Plans __ Plot Plan__ Energy Audit __Materials List __ Electrical Layout__ 
        Plumbing    Layout __
13	AFFIDAVIT
        I swear  to the best of my knowledge and belief 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 not, and that such work is authorized by the owner 
SIGNATURE  ______________________________________________     DATE  _____________________
                         (Owner or Owner's Agent) 

                      BELOW THIS LINE TO BE COMPLETED BY THE BUILDING DEPARTMENT 

ACTION ON APPLICATION
 Permit Granted Date ____________________		Signed __________________________
 Permit Denied Date _____________________		Signed __________________________
 Reason for Denial________________________________________________________________________________
 _______________________________________________________________________________________________

Variance/Special Permit Requested By ________________________________________  Date ________________
Variance/Special Permit Granted By __________________________________________  Date ________________
Certificate of Occupancy Granted By _________________________________________   Date ________________
Certificate of Compliance Granted By ________________________________________    Date ________________