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JpECEIVE)Al fice Use OnlyIHCrwntspearett||permit: AC-CoG <G020 PLICATION |Permit Fee:$129.00 Bay Road,Queensbury,NY 12804 ties - Invoice #:_24 21 P:518-761-8256 www.queensbury.net Project Location:40 (Uchigen Ave Qyeersbory AY 12 Pot Gtaxmapio#:COR.T-!24 subdivision Name: CONTACT INFORMATION: *Applicant:Name(s):__Gereld Recn Gauthrer Sleidled Craftsmen,LLC Mailing Address,C/s/z:__4732 si @i fo Acagle Ay 12209 Cell Phone:_(S'%_)%32-is 6 ¢Land Line:_() Email:Sere,©gavbles shied Crdls men com +Primary Owner(s): Name(s):Seca h Cer ter Mailing Address,C/S/Z:__#0 (usher Ave Cell Phone:(Sip)F20-186 Land Line:_() Email:Sereh Cert @ ogc.edu CO Check if all work will be performed by homeowner only ©Contractor(s):Workers’Comp documentation must be submitted with this application Contact Name(s):Gethec sk lid @ifle Llc Contractor Trade:ge ASove Mailing Address,C/S/Z: Cell Phone:_{)Land Line:_() Email: **List all additional contractors on the back of this form ©Architect(s)/Engineer(s): Business Name:Aon Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_()land Line:_() Email: Contact Person for Building &Code Compliance:Gera \d ion Cell Phone:_(<I%_}AIL 166 ¢Land Line:_{ Email: Adkition/Ateration Application Revised February 2019 PROJECT INFORMATION: TYPE:Commercial X_Residential WORK CLASS: XC Single-Family __Two-Family __Multi-Family (#of units ) __Townhouse __Business Office __Retail ___Industrial/Warehouse Garage (#of cars )Other (describe.) ADDITION SQUARE FOOTAGE:ALTERATION SQUARE FOOTAGE: Ast floor:_1 LO Ast floor: 24 floor:2"floor: 3°floor 3°floor: Basement (habitable space):Basement (habitable space): Total square feet:__\‘Lo Total square feet: ADDITIONAL PROJECT INFORMATION: 1,Estimated Cost of Construction:$__|0 O°_leooe2.If Commercial project,what is the proposed use: 3.Source of Heat (circle one):Gas Oil Propane —_— Solar other 1 8 O Fireplaces need a separate Fuel Burning Appliances &Chimney Application 2 ¢le=s Tex 4,Are there any structures not shown on the plot plan?YES (No “Explain: 5.Are there any easements on the property?vss 3) 6.SITE INFORMATION: What is the dimensions or acreage of the parcel?_6 6 <100 Is this a corner lot?Yes \NO Will the grade be changettas-re:e construction?YES What is the water source?PUBLIC PRIVATE WELL Is the parcel on SEWER or a PRI IC system?__S¢-¢ paooe ‘Additon/Alteration Application Revised February 2019 ION: 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.Ifthe work 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 by a licensed land surveyor ofall newly constructed facilities prior to issuance of acertificate of occupancy. |have read and agree to the above: PRINT NAME:tA Row SIGNATURE:_.YM Ar pate:_73,440 ‘Addition/Aeration Applicaton Revised February 2019