application Office Use Only
l >` ADDITION/ALTERATION PERMIT Permit#: QC ' 243A ' 2.QA6
APPLICATION Permit Fee:$ ')4,
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#: D6t2.—e
P:518-761-8256 www.queensburv.net
Project Location: /. /4/6 h Roe, KQ �t S I/ Ray
Tax Map ID#: S.:2 S od o2�-7.�i -I-/I Subdivision Name: '
CONTACT INFORMATION:
• Applicant:
Name(s): .Ta K 8. h e.( ,t4' i th ec..j s
Mailing Address, C/S/Z: Pa Box 'IS- 44ke Georje /Vy i "-PAS--
Cell Phone: ( t & ) 13 . -97 9 . Land Line: ( ) GG.c-. ?.3
Email: ocl ,n d> h V c.4p•Nr.canl
• Primary Owner(s):
Name(s): To'el /at'Liews
Mailing Address, C/S/Z: Po Boy
Cell Phone: ( ) 54,+ a Land Line: (
Email: $a•� e
• Contractor(s):Business Name: l e k batI/;S
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: („a! ) 7 9(o - #6. S4 Land Line: ( )
Email:
• Architect(s)/Engineer(s):
Business Name: 1-44eh at. Eri2rocehcKl
Contact Name(s): 414 c a S Jo L i 4--
Mailing Address, C/S/Z: /G 9 /44 v(fa•v,J Pit
Cell Phone: ( ) Land Line: ( ) 3a 7
Email:
Contact Person for Building&Code Compliance:
Cell Phone: ( ) Land Line: ( )
Email:
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
PROJECT INFORMATION:
TYPE: Commercial \I Residential
•
WORK CLASS:
Single Family _Two-Family _Multi-Family(#of units
Townhouse _Business Office _Retail
_Industrial/Warehouse _Garage(#of cars ) —Other(describe
l...__ION SQUARE FOOTAGE: l e ALTERATION SQUARE FOOTAGE:
1st floor: - ,/ 42' (/art4ttace. 1st floor: /� 040
2nd floor: 2nd floor: - t a o 0.•
3rd floor: 3rd floor: ,
Basement(ha• :•le space): Basement(habitable space): / 6,046
•.: square feet: 1 / ( Total square feet: 021 a 90
600 qS0k-Iraff3
ADDITIONAL PROJECT INFORMATION: 2. `C'�o
1. Estimated Cost of Construction:$ Z Q 0, 0 0 •
0
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 e xplain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? r S
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? BLIC Q-1VATE WELL
e. Is the parcel on SEWER or a PRIVA E SEPTI system?
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
•
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.
S. 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: 7e / Matt!/1 Pe.J5
SIGNATURE: DATE: S C/61-4/�
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018