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CC-0023-2020Office Use Only CC- We FT Tot O Permit Fee:$_\"15.00 Invoice #:__Q>7O Permit Town of Queensbury 742 Bay Road,Queensbury,NY 1: IKI P:518-761-8256 veww.queensburyinét Project Location: TaxMapID#:2S.WL -l-e Subdivision Name: CONTACT INFORMATION: ©Applicant: Name(s):dunn Kb (Dawid Lansy Mailing Address,C/s/z:___/45y St.lt.7 ,L6-"ny [a LIS Cell Phone:_(S/F _)_244 -2S2-landline:(51)793-2196 Email:(Ati MI@ gu).bam «Primary Owner(s): Names): Mailing Address,C/S/Z:jor —_Cell Phone:_()Land Line:_() Email: check if all work will be performed by property owner only *Contractor(s):Workers’Comp documentation must be submitted with this application Contact Name(s): Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: **List all additional contractors on the back of this form ©Architect(s)/Engineer(s): Business Name:CHhan tMyl Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land tine:_() Email: Contact Person for Building &Code Compliance:__Laima le or Dink Cell Phone:(S/f_)_321-fu Land Line:_()SP 7G6- Email:Jus [Adsition/Aitertion Application Revised January 2020, PROJECT INFORMATION:mn ResidentialTYPE: WORK CLASS: __Single-Family __Two-Family _Multi-Family (#f of units ) ___Townhouse ___Business Office __Retail ___Industrial/Warehouse ___Garage (#of cars )one (describe Po DNW\ ADDITION SQUARE BZ ALTERATION sauase FOOTAGE: Basement (habitable space):Basement (habitable space) Total square feet:Total square feet: ADDITIONAL PROJECT INFORMATION: 1 Estimated Cost of Construction:$Sooo If Commercial project,what is the proposed use:ind wall. Source of Heat (circle one):Gas Oil Propane Solar Other A Le Fireplaces needaseparateFuelBurningAppliances&Chimney Application Are there any structures not shown on the plot plan?YES NO Explain;ALA .Are there any easements on the property?YES @) SITE INFORMATION: What is the dimensions or acreage of Ce NBA boresa. b.Is this a corner lot?Yes c.Will the grade be changed as a auaotsy construction?YES fod.What is the water source?PRIVATE WELL e Is the parcel on SEWER or a PRIVATE SEPTIC system? ‘Addition/Alteration Application Revised January 2020 DECLARATION: 1.|acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within 2 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.|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.lalsounderstand 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. Ihave read and agree to the above: PRINT NAME hau a i k old signature:aut a DML pate:_/y/20 ‘Addition/Ateration Application Revised January 2020,