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APP IC U Per it Fee:$ 7,45.-; o6
TrnvnF ofQueensbury Q EENSBU .. `
742 Bay Road,Queensbury,NY 12804 BUILDING& CODES,..I� ce#: 0¶q 7
P:518-761-8256 www.queensbury.net
Project Location: 375 Bay Road Suite 101
Tax Map ID #: l L ( Cf._t-3 3 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): Jersen Construction Group- Angela Cioffi
Mailing Address, C/S/Z: 6 Industry Drive Waterford NY 1288
Cell Phone: ( 518- )779-7702 Land Line: L )
Email: acioffi@jersen.com
• Primary Owner(s):
Name(s): 375 Bay Road
Mailing Address, C/S/Z:6 Industry Drive Wateford NY 12188
Cell Phone: ( ) Land Line: (518 ) 233-0600
Email: acioffi@jersen.com
• Contractor(s):
Business Name: Jersen Construction Group
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: )
Email:
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: Angela Cioffi
Cell Phone: 518 ) 779-7702 Land Line: (
Email: acio i jersen.com
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
PROJECT INFORMATION:
TYPE: x Commercial Residential
WORK CLASS:
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: 2100
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 17,500.00
2. If Commercial project, what is the proposed use: office
3. Source of Heat (circle one): Gas Oil Propane Solar Other gas
Fireplaces need a separate Fuel Burning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? YES NO Explain: no
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel?
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? PUBLIC PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC 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.
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: 1; t\t"-Vc-LC
SIGNATURE: PCtS4(\L DATE: Va ;) ---
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018