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application Office Use Only ADDITION/ALTERATION PERMIT Permit#: 1-©60a 'L© t5 APPLICATION Permit Fee:$ Town of Queensbury 742 Bay Road,Queensbury,NY 12804 Invoice#: rv2.2 P:518-761-8256 www.queecnsburyy.net Project Location: /1Z.-7- -3ECEOWEIr' il `e��✓` �a�^ � � f �,�" >����� Tax Map ID #: 2 1 / / 1 kL ) Subdivision Name: r, MAY 142019 CONTACT INFORMATION: TOWN OF QUEENSBURY • Applicant: BUILDING&CODES Name(s): /7I , Mailing Address, C/S/Z: )774- 5 --1 ® � A P.- 5,i k, L/®v 31ie13 ,1 M1?I7a, Cell Phone: (LC)9 ) 2Z?—Z Z V Land Line: ( Email: / Qi Time /7136 /1<_. Co-. • Primary Owner(s): Name(s): Mailing Address, C/S/Z: 7'?1- t `f /Z 6 9 Cell Phone: ( ) Land Line: ( Email: ❑ Check if all work will be performed by homeowner only • Contractor(s): Workers' Comp documentation must be submitted with this application Contact Name(s): Contractor Trade: r()4AL-4, Mailing Address, C/S/Z: /79 '"�`)i(04 -7 7 / J 3? b Cell Phone: ( 4,09 ) 2- Land Line: ( Email: **List all additional contractors on the back of this form • Architect(s)/Engineer(s): Business Name: T ` T2i xz _o;Lei Contact Name(s): IP.)4 v/ -if Mailing Address, C/S/Z: 3-7.)O lid :,7 M"— >' Ceej- 7 / 7-1? Cell Phone: (1O`? ) 02-E —2---2-- Land Line: ( Email: Contact Person for Building & Code Compliance: Get-t--) ,-fr'-S Cell Phone: ( ) Land Line: ( ) Z/7 -7-60) j 307- Email: bra;(› ,^-E, 1- _ , Co 0,1 Addition/Alteration Application Revised February 2019 PROJECT INFORMATION: TYPE: c/Commercial Residential WORK CLASS: Single-Family Two-Family Multi-Family (#of units Townhouse Business Office Retail 0 Industrial/Warehouse Garage (#of cars ) Other (describere,4 � � �eq � ) ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE: 1st floor: 1st floor: 2nd floor: 2nd floor: 3rd floor: 3rd floor: Basement (habitable pa )- Basement (habi b e ,e): Total square feet:' Total square feet: ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ '70 ooD ,(710 2. If Commercialproject, what is the proposed use: - 9r--e- p p 3. Source of Heat (circle one): Gas Oil Propane Solar Other //4 Fireplaces need a separate Fuel Burning Appliances & Chimney Application` 4. Are there any structures not shown on the plot plan? YES N& Explain: 5. Are there any easements on the property? OYES NO 6. SITE INFORMATION: a. What is the dimensions or acreage of the arcel? b. Is this a corner lot? YES NO c. Will the grade be changed as a result o e construction? YES d. What is the water source? PUBLIC PRIVATE WEL e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Addition/Alteration Application Revised February 2019 DECLARATION: 1. I acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within a 12 month period. 2. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to fees and department approval. 3. I 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: 41/eic npf e 4. SIGNATURE: DATE: Addition/Alteration Application Revised February 2019