application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: Q-G - t ' " 20213
h,wn,r chnrni „ APPLICATION Permit Fee: 5 ZDO ""
742 Bay Road,Queensbuf`y,NY 12804 q
Invoice#: 2� l
P:518-761-8256 www. ueensbury.net
Project Location: �' \r`100a S\,Ye.C
Tax Map ID #: oe . 'o-- t - \4. Subdivision Name: -
CONTACT INFOF MAT ION:
• Applicant'
Name(s): . f Di?c # ,4,_ B4a—cs+c-.„ Jj 1- ,s
Mailing Address, C/S/Z: y J0,--, 44 ,F....ivu.._, *3 ( 2 • toe--
Cell Phone: (S7 1 )4.45s -C7-51 Ln, Land Line: ($7b ) Tom-/ - 262 /
Email: /14SC+04 6<-71', Q-14) ,r2yy.p- 44,5*.-lsr t-u. (-.'.'
• Primary Owner(s):
Name(s): /114-44e_ q,,,.,,,-,./
Mailing Address, C,/S/Z: /l 12 JnoP.sr41,/2 Cr". 0 ure-,.'sts'L,/1 A i 1 r f r-/
Cell Phone: ( ) Land Line: (-q--1 ) 3,i f- 61 tf
Email:
Check i1 all work will be performed by homeowner only
• Contracton(s): Workers' Comp do�umentation must be submitted with this application
Contact Name(s): I (24^-1 --rCac sG�tskit' r Jr s
Contractor Trade:
Mailing Address, C/S/Z: Li '�TY<-cam f=.4tec_._, ,/ 1 e eG-S-
Cell Phone: ( ) Land Line: ( <7 X ) - -f -/mot? I
Email:
**List all additional contractors on the back of this k
• Architect(s�/Engjneer(s):
Business Name: JUN 2 9 2023 i
Contact Name(s): Y OvvN (Yr nUFE- ISPLIRY
Mailing Address, C/S/Z: BUILDNG&CODES I
Cell Phone: ( _ ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: f'',f to AdrtA3 &CLu
Cell Phone: (*t ) 607-- o7(4, Land Line: (.S ) Z'f - Y 6 a i
Email:
Add tion/Mterenon Appficabon Revised February 7019
i\k
PROJECT INFOR ATION:
TYPE: Commercial (r--
Residential
1
WORK CLASS:
Single-Family Two-Family Multi-Family (#of units
)
Townhouse Business Office Retail
Industrial/War:house Garage (#of cars ) Other (describe )
ADDITION SQUARE OOT-GE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2'floor: 2" floor:
3'° floor: II 3r°floor:
Basement (habitable space): Basement (habitable space):
Total square f et: Total square feet:
/Ai.ST 4/L- -Gl2GSS WINS etJ
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cast of onstruction: $ s-i
2. If Commerci.I proj ct, what is the proposed use:
3. Source of He t (cirdle one): Gas Oil Propare Solar- Other
Fireplaces n:-d a separate Fuel Burning Appliances & Chimney Application
4. Are there an struclIures not shown on the plot plan? YES NO Explain:
S. Are there an ease on the property? YES NO
6 SITE INFORM.TION:
a. What is t e dim nsions or acreage of the parcel?
b. Is this a ce rner I t? YES NO
c. Will the g ade b changed as a result of the construction? YES NO
d. What is t e wat r source? PUBLIC PRIVATE WELL
e. Is the par,el on EWER or a PRIVATE SEPTIC system?
i
Addition/Alteration Apolica , Nevised February 2019
DECLARATION:
I. I acknowledge that o construction shall be commenced prior to issuance of a valid permit and will be
completed wilhin a 2 month period.
2. If the work is not •.mpleted by the 1 year expiration date the permit may be renewed, subject to
fees and depd rtme t approval.
3. I certify that 1he ap.11cation, plans and supporting materials are a true and complete statement and/or
description of the ork proposed, that all work will be performed in accordance with the NYS Building
Codes, local bidding laws and ordinances, and in conformance with local zoning regulations.
4. I acknowledgel that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
5. I also understnd th.t I/we are required to provide an as-built survey by a licensed land surveyor of all
newly construtted f:cilities prior to issuance of a certificate of occupancy.
I have read and agiee to he above:
PRINT NAME: /11/11F' Nod"✓ect--O
SIGNATURE: /--as4 __je:, DA ET - 1 /S�7t.
Additan/Alteration Apolkation Revised February 2019