application y Office use Onivot
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ADDITION/ALTERATICIN PERMIT Peimii
APPLICATION Permit Fee: $ 27 `( , VO
Tosco of Qucensbury -
742 Bay Road,Qdeensbury, NY 12504 �
invoice
P:518-761-9256 V,WVJ.ciueensburv.nat
Y'roject Location, 1Z `-i \�e)v�,�
Talc Map ID 4. �; 2 3�G 6 3�:`F :\'l- 1. 3 y- Subdivision Name: —
CONTACT INFORMATION'
e ADDlicanto
Name(s):
Mailing Address, C/S/Z: V)
Cell Phone: ( ) Land Line:
Email:
PrImary ®wner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
® Contractor(s)o
Business Name:
Contact Name(s): S"
Mailing Address, C/S/Z:
Cell Phone: Land Line: ( r--- '�—"`- --�,._
Email: J ._
® Architect(sVEngineer(s)o JUN L
8 2018
Business Name: 7TC)tnin,G-���EN&
Contact Name(s): QU1LD1NG,t ®per
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: \�r
Cell Phone: 1 ) Land Line:
Email: �t_�� I
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
PROJECT WORMA7I0)N'.
TYPE.- Commercial Residential
WORK CLASS:
VII'Single-Family Two-Family Multi-Family (#of units
Townhouse Business Office Retail
Industrial/Warehouse Garage (#of cars —Other (describe
ADDITION SQUARE FOOTAGE- ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2 nd floor:
nd
Dr: 2 floor: N\-�c \L--
3/r.'.
3 rd floo 3rdl floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: 1-t3
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ pia
2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one): Oil Propane Solar Other
Fireplaces need a separate Fuel Burning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? YES 1;6) Explain:
5. Are there any easements on the property? YES (UO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? , -L Q)c-, ���Z_
b. Is this a corner lot? YES
c. Will the grade be changed as a result of the construction? YES
d. What is the water source? OUBLIC PRIVATE WELL
e. Is the parcel on SEWER or aCR_1V_ATE SE_PT�l ystem?
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
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DECLAFRA I'l0N:
t. I acknowledge that no construction shall be commenced priof to iSSUance of a valid permit and will be
completed within a 12 month period.
2. Ifthework is not completed 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 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. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
5. I 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:
SIGNATURE: DATE:
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018