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Office Use Only ADDITION/ALTERATION PERMIT|Permit # CC 0022-2020 APPLICATION Permit Fee:$_|"}f>~ Town of Queensbury 742 Bay Road,Queensbury,NY 12804 Invoice #:_22BAG P:518-761-8256 www.queensbury.net Project Location:Adi nnd ack budt Mall Tax MapID#:__258.)2 -|-2 >Subdivision Name JKCONTACTINFORMATION: ©Applicant: Name(s):Adinndack Ovtblt Mau Mailing Address,C/s/Z:__/454 Slat 219 Lake ltoqe Cell Phone:(s/¢_)_3 2/-§U72 landline:(S/S )_743 —21 Email:admin@ adinrnderk Outlet Maud —U) +Primary Owner(s):In) Name(s):Dawid J Kenay tl Mailing Address,C/S/Z:__54 Steb 47,LG /af¥5 | Cell Phone:_(S/P_)74&-7c $2.Land Line:_() Email:djykiany C gmail «Cor (&check if all work will be performed by property owner only ©Contractor(s):Workers’Comp documentation must be submitted with this application Contact Name(s):Loay breContractorTrade:Care Corstructran Mailing Address,C/S/Z:Hvdiun Falls 1 72839. Cell Phone:(S/¢_)_ie l-0939 Land Line:_() Email:___Cadnne ConCtructinn ©Yah 00.Com **List all additional contractors on tHe back of this form ©Architect(s)/Engineer(s): Business Name:Roasla+Hall.Ethan Hall. Contact Name(s):Etvhan Hau Mailing Address,C/s/z:__/34 Dix Ave Grensfalle ny sagol Cell Phone:_(5/f_)__74/-0Ala 6 Land Line:_() Email:tphall @ ay ap.rite Contact Person for Building &Code Compliance:Link Cell Phone:_(.5if_)744-752.land Line:_(vf )793°3196 Email:Ay Linny ©gmtul.Lor ‘Adeition/teration Application Revised January 2020, PROJECT INFORMATION: TYPE:X Commercial Residential woRrK CLASS: __Single-Family __Two-Family __Multi-Family (#of units ) ___Townhouse ___Business Office _X Retail __Industrial/Warehouse Garage (#of cars )Other (describe ) ADDITION SQUARE FOOTAGE:ALTERATION SQUARE FOOTAGE: Ast floor:(e(12. 2"floor:r= 34 floor:i Basement (habitable space):Basement (habitable space): Total square feet:nla Total square feet:__(#00 ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$_fo,00) If Commercial project,what is the proposed use:Wikre he Lode Source of Heat (circle one):Gas Oil Propane —Solar_—Other alae Fireplaces need a separate Fuel Burning Appliances &Chimney Application Are there any structures not shown on the plot plan?YES GO)Explain: Are there any easements on the property?YES @® SITE INFORMATION: What is the dimensions or acreage of the parcel?_~7-5 aoys4 Is this a corner lot?YES Will the grade be changed as a result of the construction?YES What is the water source?Coa PRIVATE WELL Is the parcel on SEWER or a PRIVATE SEPTIC system?__.d¢0ue™ eens [Addition/Ateration 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 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.|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.lalso understand that |Ave are required to provide an as-built survey byalicensedlandsurveyorofall newly constructed facilities prior to issuance of a certificate of occupancy. Ihave read and agree to the above: PRINT NAME:wi ny SIGNATURE:CLL A.DATE:123 ]2v2© ba —3— ‘Addition/Alteration Application Revised January 2020,