application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: i032 ®�
APPLICATION Permit Fee: $ 2C2 O , L'O
Town of Queensbury-
742 Bay Road,Queensbury,NY 12804 ! #�'� '3
P:518-761-8256 www.queensbury.net _
EcEavEl \
Project Location: 54,3 oe,s (t1U l
u SUN 0 7 2019 W
Tax Map ID #: 30 Ts0\1015VeThuRI
f��3�S
CONTACT INFORMATION:
• Applicant:
Name(s): , ►(d—
Mailing Address, C/S/Z:
Cell Phone: ( 3 ) -orlir Land Line: (
Email: A(F,,v tc O N.j A A f C.l6,°L
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
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:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: (
Email:
Addition/Alteration Application Revised February 2019
.
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Single-Family Two-Family Multi-Family (#of units )
r
Townhouse Business Office Retail
Industrial/Warehouse Garage (#of cars ) _Other (describe )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ /yam
2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one): Ga Oil Propane Solar Other
Fireplaces need a separate F Burning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? YES VA Explain:
5. Are there any easements on the property? YES
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? Z(3 tAut,
b. Is this a corner lot? YES 69'
c. Will the grade be changed as a result of the construction? YESNY
d. What is the water source? PUBLIC PRIVAI
IELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? '5p 4L
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: ectj RfIcAlti6i
SIGNATURE: DATE: C(31(7
Addition/Alteration Application Revised February 2019