application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: I, C — O f" (— 17
APPL EPC EE a V Pe nitFee: $ 20 U: OU
Tone of(Luecnsbury
742 Bay Road,Queensbury,NY 12804 Invoice#: I I ?
P:518-761-8256 www.queensbury.net JAN 2 4 2019
Project Location: S LM7 S-ipf& TOWN OF QUEENSBURY
1 BUILDING&CODES
Tax Map ID #: 30 _ 1 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): (ea
Mailing Address, C/S/Z: code-Ms Liu , ASsoJ , i //,t A) , i . ) 4�39
Cell Phone: ( 5')$' ) Land Line: (
Email:
• Primary Owner(s):
Name(s): (J,t p (c)Ar. '
Mailing Address, C/S/Z: S L,i4 -s/r ppen LAM'
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): �yy -y
Business Name: Co/i€t110 C
Contact Name(s): /lea G //ef
Mailing Address, C/S/Z: 3 ("e/(e ,l' /-,oU • // f. / aFyq
Cell Phone: ( 5-/S ) 3'5' .2-v- 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: 43 (-,/lc' 11-
Cell Phone: ( ) 6 J_ 2 g Land Line: ( )
Email:
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
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
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor: a C6
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space): 1"
Total square feet: Total square feet: Li 513
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $_ � zT)
2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one): Gai, 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 ( '1 Explain:
5. Are there any easements on the property? YES
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? d 4 g Ae
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? PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? S' p7
Town of Queensbury Budding&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.
Eu, ICQ,� all- )/0'5'4;1 11)6 � 2e,5's OrU i�S ¢ � C�j/ZesS 4o
4
I have read and agree to the above:
PRINT NAME: 4'pj („, a
-tr,
SIGNATURE: DATE: //02 )- /
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018