application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: L
APPLICATION Permit fee:$ I t�
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#: 1E) l;P
P:518-761-8256 www.gueensbury.net
Project Location:
Tax Map ID#: d-1 u I y Z 2 Subdivision Name:
CONTACT INFORMATION:
• Applicant: (
Name(s): Rbbe_r+ S_ t C
Mailing Address, C/S/Z: 35 a�,ee"V..s A)
Cell Phone: (�8 ) 30-7- '391 V7 Land Line:
Email:—r- slrk . VLV MeiCovyA
Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line:
Email:
• Contractor(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line:
Email:
.._. a It,
• Architect(s)/Engineer(s): � i}
Business Name:
Contact Name(s): 41
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line: � )
Email:
Contact Person for Building & Code Compliance: V-t'. - cte-, k
Cell Phone: Land Line:
Email:
Town of Queensbury Building&Code Enforcement Addition/Akeration Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial /Residential
WORK CLASS:
Single-Family _Two-Family _Multi-Family(#of units )
Townhouse Business Office Retail
_Industrial/Warehouse _Garage (#of cars j _Other(describe )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor:_ :Z�3.5 1st floor:
2"dfloor: Z S3, 5 2"d floor:
3rd floor: 3rd floor:
4th floor: 4th floor:
Total square feet: l Z ` -t•' Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ • c Gr�'' 415
2. If Commercial project,what is the proposed use:
3. Source of Heat (circle one): Gas Oil �iances
Solar Other tlec l"C_
Fireplaces need a separate Fuel Burning Ahimney Application
4. Are there any structures not shown on the plot plan? YE NO Explain: � -
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of theparcel? l OLc ire,5
b. Is this a corner lot? YES NO
c. Will the grade be changed as a resut the construction? YES 4 O
d. What is the water source? BLIC PRIVATE WELL
e. Is the parcel on SEWER orRIVATE SEPTIC ystem?
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017
� 4
DECLARATION:
1. 1 acknowledge that no construction shall be commenced prior 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. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
5. 1 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: Chi * �t-1(
SIGNATURE: P /�/ DATE: /r7
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017