application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: CC - 0 S 767-2 O
APPLICITION \Vj
Town ofQuueensbury Permit Fee: $
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net II AUG 26 2019 i invoice#:
Project Location: 190 Quaker Road OWN OF QUEENSB°'`_DING&CODES ti
Tax Map ID #: 3d2 , -7-1-Mi Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): Ted Simmons_
Mailing Address, C/S/Z: 1004 Hudson River Road, Mechanicville, N.Y. 12118
Cell Phone: (518) 390-9392 Land Line: (518)6641315
Email: tsimmons@pnmconstruct.com
• Primary Owner(s):
Name(s): Hannaford Bros
Mailing Address, C/S/Z: 145 Pleasant Hill Rd., Scarborough, ME. 04074
Cell Phone: (207)671-0665 Land Line: (717)960-1700
Email: Christopher.sargent(a,delhaize.com
❑ Check if all work will be performed by homeowner only
• Contractor(s):
Contact Name(s): P&M Construction/ Ted Simmons
Contractor Trade: General Contractor
Mailing Address, C/S/Z: 1004 Hudson River Road, Mechanicville,N.Y. 12118
Cell Phone: (518)390-9392 Land Line: (518)664-1315
Email: tsimmons@pnmconstruct.com
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: L2M
Contact Name(s): Jon Towle
Mailing Address, C/S/Z: 90 Bridge St., Suite 420. Westbrook, ME. 04092
Cell Phone: _( ) Land Line: (410)863-1302 X-301
Email:jtowle@L2M.com
Contact Person for Building & Code Compliance: Chris Sargent
Cell Phone: (207)671-0665 Land Line: (717)960-1700
Email: Christopher.sargent@delhaize.com
Addition/Alteration Application Revised February 2019
• Contractor(s):
Contact Name(s): MG Construction & Electric/ Matt Groff
Contractor Trade: Electrical
Mailing Address, C/S/Z: 97 Edie Road, Saratoga Springs, NY 12866
Cell Phone: (518)366-4955 Land Line: (518)366-4955
Email: mgroffl02@gmail.com
• Contractor(s):
Contact Name(s): Croyle's Quality Contracting/Jamie Croyle
Contractor Trade: Taper and painter
Mailing Address, C/S/Z: _974 State Rte 67, Ballston Spa, NY 12020
Cell Phone: (518)605-7588 Land Line: (518)889-5028
Email: - cgcpainting@gmail.com
• Contractor(s):
Contact Name(s): Rufis Dunright/ Barney Waldron
Contractor Trade: Roofing
Mailing Address, C/S/Z: 1119 Catalyn Street, Schenectady, NY 12303
Cell Phone: (518)-857-8994 Land Line: (518)381-6878
Email: bwaldron@nycap.rr.com
• Contractor(s):
Contact Name(s): J&M Inc/Mark Foye
Contractor Trade: Flooring
Mailing Address, C/S/Z: PO Box 1087, Westbrook, ME 04098
Cell Phone: (207)749-6506 Land Line: (207)854-413
Email: mark@jmincflooring.com
• Contractor(s):
Contact Name(s): JDJ Comfort Systems/Jon James
Contractor Trade: HVAC
Mailing Address, C/S/Z: 44 Brickyard Rd, Mechanicville, NY 12118
Cell Phone: (518)857-2863 Land Line: (518)857-6131
Email: john@jdjcomfortsystems.com
• Contractor(s):
Contact Name(s): Alarm & Suppression Inc/ Pat Carver
Contractor Trade: Fire alarm
Mailing Address, C/S/Z: 331 Ushers Road, Ballston Lake, NY 12019
Cell Phone: (518)775-0504 Land Line: (518)399-5110
Email: pcarver@alarmandsuppression.com
Addition/Alteration Application Revised February 2019
• Contractor(s):
Contact Name(s): Ace Line Striping / Bruce Milkin
Contractor Trade: Parking lot stencil and striping
Mailing Address, C/S/Z: 11 Katelyn Place East, Greenbush NY 12061
Cell Phone: (518)669-4660 Land Line: (518)785-0096
Email: bmilkins@yahoo.com
• Contractor(s):
Contact Name(s): Firetek Sprinkler Systems LLC / Bob Wood
Contractor Trade: Fire suppression- Sprinkler
Mailing Address, C/S/Z: 58 Hudson River Rd, Waterford, NY 12188
Cell Phone: (518)361-2084 Land Line: (518)244-3772
Email: rwood@alltekenergy.com
• Contractor(s):
Contact Name(s): Allerdice Commercial Doors/ Curtis Latzko
Contractor Trade: Doors and windows
Mailing Address, C/S/Z: 120 Excelsior Ave., Saratoga Springs, NY 12866
Cell Phone: (518)584-3985 Land Line: (518) 584-1127
Email: Curtis@allerdice.com
• Contractor(s):
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Contractor(s):
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: ® Commercial ❑ Residential
WORK CLASS:
❑ Single-Family ❑Two-Family ❑Multi-Family (# of units )
❑Townhouse ❑Business Office ❑Retail ❑ Industrial/Warehouse
❑ Garage (#of cars ) ❑ Other (describe Grocery store )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor: 664
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: 664
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 181,678.00
2. If Commercial project, what is the proposed use: Hannaford to Go
3. Source of heat: ®Gas❑Oil❑Propane❑Solar ❑Other Fireplaces need a separate Fuel
Burning Appliances & Chimney Application
4. Are there any structures not shown on the plot plan? OYES NO Explain:
5. Are there any easements on the property? OYES ®NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? 7 acres (+) or (-)
b. Is this a corner lot? OYES a 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? Sewer
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: Ted Simmons
SIGNATURE: DATE: P I22-I11
Addition/Alteration Application Revised February 2019