application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: C. / 3 e,2o 19
APPLICATION Permit Fee: $ o?,5`�
Town of Qucensbury
742 Bay Road,Queensbury,NY 12804 Invoice#: /-gl
P:518-761-8256 www.queensbury.net
Project Location: Y37 -7-&-- >\Wst � ��-'Tt 143
Tax Map ID #: . -/- � Subdivision Nabnet r-=2 c E
CONTACT INFORMATION: i MAR. 1 Z 2019
• Applicant:
RY
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Name(s): .A`Yl1 �
!cmrc `)fA-C S4 i r r� Nr" ' ��°" ENSG
Mailing Address, C/S/Z: ?-O Ok I (0O5 Y\ LC.n--ct rvs .•\ 12-$15/
Cell Phone: ( 8 ) f S"' QiOO I Land Line: ( ) )
Email: - PS4 cc,,‘Nr‘o\c'.iryk c acrI, oam
• Primary Owner(s):
N a m e(s): � (llpc e - 1^4 Y\ _
Mailing Address, C/S/Z: nsf,. -39 `� t►� OJ'
Cell Phone: ( SI g ) (0$3 e 0720 Land Line: (
Email: S\o0e f _l _ . Ut_ eUW\
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): j''nl rcm.j, i%f YA.Zt LcD-e( K
Contractor Trade:
Mailing Address, C/S/Z: X I (005
Cell Phone: ( 5 t ) � `v/` NoN Land Line: (
Email: t1£sT h;11 —kcz it\v_e 1pf.‘•<\L,k M A k L C CJYY\
**List all additional contractors on the back cif this form
• Architect(s)/Engineer(s):
Business Name: i \\ 4'\?CY1
Contact Name(s):
Mailing Address, C/S/Z: I.')(( 7.71)l 1-kf -
Cell Phone: ( ) Land Line: ( 8 ) 97 (2eii
Email:
Contact Person for Building & Code Compliance: :ern C(NN\--0(cn
Cell Phon • ( ) SSN r 016401 Land Line: ( )
Email: V\iNM A c CRPM 1 Svc t m L. curl
Addition/Alteration Application Revised February 2019
4.
PROJECT INFORMATION:
TYPE: J 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: Li
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: -5 -°'
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 6 06()
2. If Commercial project, what is the proposed use: - i'L C
3. Source of Heat (circle one): G) Oil Propane Solar Other
Fireplaces need a separate Vet Burning Appliances & Chimney Application
4. Are there any structures not shown on the plot plan? YES NO Explain:
5. Are there any easements on the property? YES
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? 'r,„il4.it..
Addition/Alteration Application Revised February 2019
w h
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: fCA
SIGNATURE: DATE:
3.I2-_
Addition/Alteration Application Revised February 2019