application RECEpeE
. • Bice Use Only
ADDITION ADIT ICE IT CC -co - l
APPLICATL "`:�"�' ----� Permit Fee:$ I-757 6O
OUBENBBUR
7itrvrr uI(Ziaensbury
BUILDPNO 2 COOPS l oice#:
742 Bay Road,Queensbury,NY 12804 Z y z
P:518-761-8256 www.queensbury.net
ECEOWErni
Project Location: / 70 Svc.�e D
y •FEB 19 2019 EIJJ
Tax Map ID#: 029O- £ _ / - Se. / Subdivisi N e:
TOWN OF OUEENBBURY
CONTACT INFORMATION: - BUILDING R ODES
• Applicant:
Name(s): Par .27
Mailing Address, C/S/Z: /6 S'S 2e'et, ao c+L / 0)re dcii-y ' 'O`1
Cell Phone: (Si' ) ,5-3 g - 77841 Land Line: ( 570 ) .24'8-.25 9 7
Email: l;J-n4-,, S° a 4 re'ectd 00 fetiC. r6/1/
• Primary Owner(s):0 Name(s): ti;stn-e y Pk) e I/ rs=e. i i gJ/
Mailing Address, C/S/Z: /6 5'S /2r' { Pogo c)r-ekts6d,-y /k /,r7 'C y
Cell Phone: ( Si$' ) ,;3 g - 7 7g -/ Land Line: ( Si g' ) oZ ve -02 5 9
Email: t.►e. S'`fo✓' ed agog ei r Con'I
• Contractor(s):
Business Name: S"14-0Y1'cd EOetdddS' LPL C.
Contact Name(s): /C. 2 RasS'e//
Mailing Address, C/S/Z: h //'443 /cco Lok'•e cV f /028'VS
Cell Phone: 5/i' ) a S-- '/9/ 7 Land Line: ( S/8 ) c7 7 q
Email: `Tr /.1.2 S4- r r'Cd bc'4rdc . Co 4I
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s): Nefet:el I O iff"S/-/
Mailing Address, C/S/Z:
Cell Phone: ( 5i$ ) 76 V - 3/3 2 Land Line: (
Email:
Contact Person for Building & Code Compliance: (tin �ti PaS 5e--//
Cell Phone: ( j/K ) S 3 '- 77 g`/ Land Line: ( ' )
Email: (A) � �vt e y S"ta P/eaQ Oa✓d5 . (O -el
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 i4/1ir•04,07ts O/7/7 )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor: yyo
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: $ `3Si o200
2. If Commercial project, what is the proposed use: 4 2 //c, c_keoyc)
3. Source of Heat (circle one): Gas Oil Propane Solar Other fLL 2dr Sree
Fireplaces need a separate Fuel Burning Appliances & Chimney Application
4. Are there any structures not shown on the plot plan? YES NO xplain:
5. Are there any easements on the property? NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? /4• S�
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES
d. What is the water source? PUBLIC PRIVATE WEL�
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Sc/afiL
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-- . _ __�� - /-.
SIGNATURE: i4 h, t ,e_` PJ5-C // DATE: a//g /q
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018