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CC-0003-2020Office Use Only Permit CC -b003 -2020ADDITION/ALTERA’ afmeds§18.00APPLICATI Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net AXice we)Z AGS: Project Location:_310 Dixon Road Tax Map ID #:523400-302-009-0001-001-000-0000 Subdivision Name: CONTACT INFORMATION: Applicant: Name(s):_Cifone Construction Co.Inc. Mailing Address,C/S/2:PO Box 684 Glens Falls,NY 12801 Cell Phone:(518 _)361-0626 land Line:_(518)792-9242 Email:_mcifone@cifone,com Primary Owner| Name(s):Bryan Schuer! Mailing Address,C/S/Z:_7 Helen Drive Queensbury,NY 1204 Cell Phone:_(518 _)538-1300 Land Line:518 _)_338-3405 Email:_blizzard1287@yahoo.com O Check if all work will be performed by homeowner only Contractor(s):Workers’Comp documentation must be submitted with this application Contact Name(s):Cifone Construction Co.Ine. Contractor Trade:_GC Mailing Address,C/S/Z:_PO Box 684 Glens Falls,NY 12801 Cell Phone:_(518 _)361-0626 Land Line:(518 )792-9242 Email:_mcifone@cifone.com List all additional contractors on the back of this form Architect(s)/Engineer(s): Business Name: Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_()land Line:_() Email: Contact Person for Building &Code Compliance:_Matt Cifone Cell Phone:(518 _)361-0626 Land Line:(518)7929242 Email:_mcifone@cifone.com Adsition/Niteration Application Revised February 2019 PROJECT INFORMATION: TPE:Y_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: Basement (habitable space):Basement (habitable space): Total square feet:Total square feet: ADDITIONAL PROJECT INFORMATION: 1,Estimated Cost of Construction:$_2500 2.If Commercial project,what is the proposed use:_exam room 3.Source of Heat (circle one):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 QD Explain: 5.Are there any easements on the property?YES aD 6.SITE INFORMATION: 21,214sqftWhatisthedimensionsoracreageoftheparcel Is this a corner lot?YES iO Will the grade be changed as a result of the construction?YES © What is the water source?PRIVATE WELL Is the parcel on SEWER or a RRIVATE SEPTIO system? peaore Addition/Alteration Application Revised February 2019, DECLARATIOI 1.Lacknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within a 12 month period 2.Ifthework 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.|acknowledge that prior to occupying the facilities proposed I,or my agents,will obtain a certificate of occupancy. 5.lalso understand that Ave 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. have read and agree to the above: PRINTNAME:MattCifonesionarure:Matthew J Gone pare: o=Cifone Const.Co.Inc.,ou, G l fo ne ‘email=mcifone@cifone.com,c=US Date:2020.01.06 10:52:19 -05'00" Adéition/Ateration Application Revised February 2019