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a Office Use Onh ADDITION/ALTERATION PERMIT|Permit #:~2erO APPLICATION Permit Fee:$__17S.00Tm 742 Bay Road,Queensbury,NY 12804 Invoices 249 P:518-761-8256 www.queensbury.net Project Loe:BIS StokeRoute |)MAR 02 2020 tax Mapp #:SAZYUOO 302.5 -|-P Buraivision ame: CONTACT INFORMATION: Applicant: Name(s):3A Chambers,LLC Mailing Address,c/S/2:___29S¢(aja Shore b-_(akeCeaxre NY (284 Cell Phone:(SI.)SOl-37>]Land Line:_() Email:pChambers @ fhefire place co.CO +Primary Owner(s):—,Name(s):raul Chambers Mailing Address,C/S/z:_IS Lakee [Coack Diamar rant NY 79a Cell Phone:_()_Bol -273/Land Line:_() Email:, [Check if all work will be performed by homeowner only ©Contractor(s):Workers’Comp documentation must be submittedwiththisapplication Contact Name(s): Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: **List all additional contractors on the back of this form *Architect(s)/Engineer(s): Business Name: Contact Name(s): Mailing Address,C/S/2: Cell Phone:_()Land Line:_{) Email: Contact Person for Building &Code Compliance:.out Leck lass Cell Phone:(5/E )Aol -2 Land Line:_( Email:pchambers a.the -fireplaceco Com Adation/Aeration application Revised February 2018, v* PROJECT INFORMATION: TYPE:SL commercial WORK CLASS: ___Single-Family __Two-Family __Townhouse X.Business Office ____Industrial/Warehouse ___Garage (#of cars ADDITION SQUARE FOOTAGE: Ast floor: 2"floor:3 floor: Basement (habitable space): Total square feet: ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$ Residential __Multi-Family (#of units ) __Retail )_Other (describe.) ALTERATION SQUARE FOOTAGE: st floor:_40 Basement (habitable space): Total square feet:_//9O £00. 2.If Commercial project,what is the proposed use:_¥rode ling interctor™Space 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 5.Are there any easements on the property? 6.SITE INFORMATION: &)Explain: reel?BH AY Qoresa,What is the dimensions or acreage of the b.Isthisa corer lot?YES ¢.Will the grade be changed as a result of the construction?YES (0) d.Whats the water source?(PUBLIC) ~— PRIVATE WELL e.Is the parcel on BEWER o}a PRIVATE SEPTIC system?OWN SCwer— Aciition Alteration Application Revised Febrvary 2019 DECLARATION: 1,|acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within a 12 manth 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 @ 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.also understand that Ave are required to provide an as-built survey by a licensed land surveyor ofall newly constructed facilities prior to issuance of a certificate of occupancy. Ihave read and agree to'the above: PRINT NAME,aulChelWS SIGNATURE:galsve DATE:apfo0 (<7 ‘Addition Beration Aplicetion Revised February 2019,