application Office Use Only
1 ADDITION/ALT PIT -(—R *t#: -61
E V
APPLI A r ' Fee: $ Z.S
Town of Qyeensbury
742 Bay Road,Queensbury,NY 12804 MAY 10 2019 I i #: / S/4-
P:518-761-8256 www.queensburv.net i
TOWN OF QUEENSBURY
Project Location: 114 Sunnyside North, Quee 9 sbury;:WILDING&CODES
Tax Map ID #: 279.17-2-14 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): Ronald Egnaczyk
Mailing Address, C/S/Z: 114 Sunnyside North/Queensbury/NY/12804
Cell Phone: {518281 7042)518 281 7042 Land Line: { )
Email:joyce.Egnaczyk@tglawyers.com
• Primary Owner(s):
Name(S): Ronald Egnaczyk
Mailing Address, C/S/Z: 114 Sunnyside North/Queensbury/NY/12804
Cell Phone: (518 281 7042)518 281 7042 Land Line: ( )
Email:joyce.Egnaczyk@tglawyers.com
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: Creation Studios 9
Contact Name(s): David Hutchinson
Mailing Address, C/S/Z: 26 Catherine Street
Cell Phone: ( )518 683 4608 Land Line: ( )
Email:creationstudios9@yahoo.com
Contact Person for Building & Code Compliance: PIPV/O i (01/4/
Cell Phone: (3/$ ) 6 /16049 Land Line: ( )
Email: ('Kt-a, oi�' � e2C.
Addition/Alteration Application Revised February 2019
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): GAUTHIER SKILLED CRAFTSMAN LLC. -JOSH BROWN
Contractor Trade: General
Mailing Address, C/S/Z: 4732 STATE ROUTE 40,ARGYLE, NY 12809
Cell Phone: ( )518-431-5555 Land Line: (
Email:Jerry@gauthierskilledcraftsman.com
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: { ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
X 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: 124 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: 124 Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $25,000
2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one): Gas 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 Explain:
5. Are there any easements on the property? YES
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? 5,179 s.f.
b. Is this a corner lot? YES
c. Will the grade be changed as a result of the construction? YES
d. What is the water source? PUBLIC PRIE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Private Septic
Addition/Alteration Application Revised February 2019
4 �
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 f/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: ncac,e_ C ,,0 •,2
SIGNATURE: � � DATE: s1;// -
Addition/Alteration Application Revised February 2019