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Office Use Only ADDITION/ALTERATION PERMIT|Permit:@&-OD%%=22APPLICATIONPermitFee:$_280-00Tom 742 Bay Road,Queensbury,NY 12804 Invoice #:_\°\F2:518-761-8256 www.queensbury.net Project Location://0 Sj ceahuey,mw A ECEIVE Tax Map ID #:Subdivision Name:Ft AUG-26-2619 CONTACT INFORMATION:TOWN OF QUEENSBURY BUILDING &CODES.AnelcansName(s):40M,ayy Consteve pyar. Mailing Address,C/S/2:“44/7 KeumKl]£) Albawy WZ Cell Phone:(.5//_)37f-fBA Land line:(S75 _)A50-¢V7B email:\AU/D #-CHAINYK @ YAz10 dom «Primary Owner(s):. Name(s):Maubren!Snth Mailing Address,C/S/Z:1 Levina-bn Lien aeAadogA-Speings AX Cell Phone:(S79 _)_¥79-3Alb ©Land Line:_() Email_dante Sh—78 eHbraitiL Cay O Check if all work will be performed by homeowner only *Contractor(s):Workers’Comp documentation must be submittedwiththisapplication Contact Name(s):Ae bh CHAIWY Contractor Trade:_(ener ay CarteAg fs Mailing Address,C/S/Z:Kk f Cell Phone:(57 )BT"552,landline:(279 email DAV J)4 CHAI XK @ AHO,Com *#List all additional contractor$on the back of this form *Architect(s)/Engineer(s} Business Name:Je ALEA)7meoical 4 deAaETING. Contact Name(s):orange Qs poeue-Hellee Mailing Address,C/S/z:333 King key.kon”Bukot Hills,A/a aDCellPhone:land Line:_(57¥) Email:AE cRVER!ven design @ alle Com. Contact Person for Building &Code Compliance:—aaaCellPhone:_()Land Line:_() Email: _Multi-Family (#of units ) __Other (describe PROJECT INFORMATION:yA TYPE:Commercial Residential worK€lass: Single-Family __Two-Family __Townhouse ___Business Office __Retail ___Industrial/Warehouse __Garage (#of cars ) ADDITION SQUARE FOOTAGE: Basement (habitable space): Total square feet: ADDITIONAL PROJECT INFORMATION: Kom % 1.Estimated Cost of Construction:$_of),077 2.If Commercial project,what is the proposed us 3.Source of Heat (circle one):Gas Oil ALTERATION SQUARE FOOTAGE: ast floor:/7/G2"floor: 3"floor: Basement (habitable space):LUTotalsquarefeet Solar Other Fireplaces need a separate Fuel Burning Ap}§&Chimney Application 4.Are there any structures not shown on the plot plan? 5.Are there any easements on the property? 6.SITE INFORMATION: What is the dimensions or acreage of the parcel? Is this a corner lot?YES (wo) Will the grade be changed as a result of te construcpangs YES YES (9) NO.Explain: = What is the wats 2 PUBLIC PRIVATE WELL Is the parcel of SEWEDor a PRIVATE SEPTIC system? ‘TION: 1.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 thework is not completed by the 1 year expiration date the permit may be renewed,subject to fees and department approval 3.|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,|acknowledge that prior to occupying the facilities proposed |,or my agents,will obtain a certificate of occupancy. 5.also understand that IAve are required to provide an as-built survey by alicensed land surveyor of all newly constructed facilities prior to issuance of a certificate of occupancy. Ihave read and agree to the above: