application Office Use Only
�, A ADDITION/ALTE Rc —c, J- '1 2'
APPLIC \V ` ZC�ca v D
Town sup{ scrasbrtr _
742 Bay Road,Queensbury,NY 12804 ti SEP 1 if 201B In #: 0$ (a
P:518-761-8256 w . ueensbury.net
�1 TOWN OF QUEENSBURY
S
Project Location: ICArlte-CY\ \r BUILDING�`_C�DF
J
Tax Map ID #: act. 1-1:- I"' O 8 Subdivision Name:
CONTACT INFORMATION:
• Applicant: f
Name(s): 0 4s \I'J \ C r5 !� C,�'��� I (c
Mailing Address, C/S/Z: 2.'1 Car lir., '" 0 W tAC 11%154
Il 7
Cell Phone: �� ) �' Z �� C� Land Line: ( )
Email: f1v 11 i ek_m5 bc) 1 h.)-NnCSc:i• v(,.(_
• Primary Owner(s):
Name(s): 7)1011/A-S -- �, c L 0;If -
Mailing Address, C/S/Z: 3.1 (C W l UY) O( Q u-[.4--)sb4,c
Cell Phone: ( 50 ) -1 "?"!Gc Land Line: ( )
Email: o , a 11( oms , b&l i 0 e sj. a r
• Contractor(s):
Business Name: I
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s): Dr,C----1— Gw 1/4An ki2,r — Ci,,rt V ., f tL.1/4nS
Mailing Address, C/S/Z:
Cell Phone: ( S7 - ) t".+t$' ---M ca90 Land Line: ( )
Email: -se_1oun i-V, 03 ,, 1 , t om
Contact Person for Building & Code Compliance: 5vm4Fn Vatiok,Lnk-Q-C
Cell Phone: ( ) Land Line: ( )
Email:
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
4
PROJECT INFORMATION:
TYPE: Commercial 7' Residential
WORK C SS:
Ingle-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: )L-1°
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: 1)
ADDITIONAL PROJECT INFORMATION: •
1. Estimated Cost of Construction: $ 5"Q0O
2. If Commercial project, what is the proposed use: Xt rcYo 1
3. Source of Heat (circle one): Gas' Oil Propane Solar Other
Fireplaces need a separate e✓Burning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? YES 61-0- Explain:
5. Are there any easements on the property? YES CNO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the arcel? a ;4 IonK J�(ac i"
b. Is this a corner lot? YES N �;k
c. Will the grade be changed as a r e construction? YES6._..)
d. What is the water source?. PUB PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? fY.\ vct cee hL
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: j\J 1 Lam < \\tOt ax`S
SIGNATURE: TAAL) WALL:: DATE:
f6 s Mitt. °`+'v‘S
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018