application Office Use Only
I ADDITION/ALTERATION PERMIT Permit#: CC... O?ll - 2Q.1c
APPLICATION Permit Fee:$ Z1Q1-0. 0 Co
Town of Queensbury 22
742 Bay Road,Queensbury,NY 12804 Invoice#: 1,rJ
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P:518-761-8256 www.queensbury.net
Project Location: 6 Willowbrook Rd.
Tax Map ID #: Subdivision Name: \ 1,4k1
CONTACT INFORMATION: N OW C1 & Y;
• Applicant:
Name(s): 117,0tivert tatie4, Fe.c` k ( sc ‹w,
Mailing Address, C/S/Z: i << rr 12et
Cell Phone: ) I L-1 Land Line: (S S S ) 72 - 1
Email: @64-4444-66?i C. �c) 0itti '. . C- .
• Primary Owner(s):
Name(s): Learning Care Group Contact: Ed Cox
Mailing Address, C/S/Z: 21333 Haggerty Road Suite 100 Novi, MI 48375
Cell Phone: ( 267 ) 897-0886 Land Line: { )
Email: ecox@learningcaregroup.com>
El Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): 3 cv c:rt t
Contractor Trade: (, Coo.r `o,r°
Mailing Address, C/S/Z: (03 S Ike l ` r
Cell Phone: ( 3 ) - 2.4 e., Land Line: ( ' ) 462.,
Email: , dvt A (`a ,o eft e,;,°,a17r .4-'7' aat
**List all additional contractors on the back di this form
• Architect(s)/Engineer(s):
Business Name: KLS Architect
Contact Name(s): Kurt L. Schmitz
Mailing Address, C/S/Z: 1770 Detroit Ave. Cleveland, OH. 44107
Cell Phone: ( ) Land Line: ( 216 ) 521-5134
Email: kschmitz@adaarchitects.cc
Contact Person for Building & Code Compliance: Javier Cora
Cell Phone: ( ) Land Line: ( 216 ) 521-5134
Email: jcora@adaarchitects.cc
Addition/Alteration Application Revised February 2019
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): IFS Integrated Facility Solutions Contact: James Warner
Contractor Trade: General Contractor
Mailing Address, C/S/Z: 841 Holt Road Webster, NY 14580
Cell Phone: ( 585 ) 738-4439 Land Line: ( 585 ) 872-4611
Email: jamesw@integratedfacilitysolutions.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: I )
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: I ) Land Line: I )
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: X Commercial Residential
WORK CLASS:
Single-Family Two-Family Multi-Family (#of units
Townhouse Business Office Retail
Industrial/Warehouse Garage (#of cars ) X Other(describe Daycare
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 8,900 1st floor: 0
2"floor: 0 2nd floor: 0
3rd floor: 0 3rd floor: 0
Basement (habitable space): 0 Basement(habitable space): 0
Total square feet: 8,900 Total square feet: 0
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ( S, 7
2. If Commercial project, what is the proposed use: daycare facility
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 NO Explain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel?
b. Is this a corner lot? ® 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?
Addition/Alteration Application Revised February 2019
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: svij, t2r
SIGNATURE: � DATE: \\\\e\
Addition/Alteration Application Revised February 2019