CC-0120-2020 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: CC D\ZO 2s3
APPLICATION ��� :-•Per-mit Fee:$ "
Town of Quccnsbury / I-, f �•�J I' R .I
742 Bay Road,Queensbury,NY 12804 I�"-�---u�y �--_� Invoice#: ?,At I
P:518-761-8256 www.queensbury.net 11 I n °
Project Location: '6
Cof
Tax Map ID#: 's A Subdivision Name:
CONTACT.INFORMATION:
• Applicant:
Name(s):
Mailing Address, C/S/Z:
Cell Phone (9 l` ) ' (o' ) ` - 3 Land Line: ( . )
Email: 0�3 N (v rf
• Primary Owner(s):
Name(s): ..
Mailing Address, C/S/Z:
_ _Cell Phone: ( ) Land Line: ( )
Email:
pCheck if all work will be performed by homeowner 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: 'Ll _, �.� C—
Contact Name(s):
Mailing Address, C/S/Z: . .
Cell Phone: ( ) - Land Line: ( )
Email:.
Contact Person for Building & Code Compliance: ,lower. _
Cell Phone: (G/6 }- 12-`" 3 Land Line: ( )
Email: m<71-'vi S�l S' �Y1 L. > C vv‘
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:.
Single-Family Two-Family _ Multi-Family (#of units ) .
Townhouse Business Office -1c7 Retail
Industrial/Warehouse X< Garage(#of cars .) _Other (describe
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: } ) 1st floor: 15a`Zi
2nd floor: • 2nd floor: _ _ - -
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ f .
2. If Commercial project, what is the proposed use: 2 4Tb -i
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 . . Explain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? • e 7 ��
b. Is this a corner lot? YES CO) _ _ _
c. Will the grade be changed as a r2,.u1 .c f the construction? YES - NO .
d. What is the water source? UBL PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? *Nivk-
Addition/Alteration Application Revised February 2019
DECLARATION:
1. I acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period.
2. If the work is, not completed by the 1 year expiration date the permit" may be renewed, subject to
fees and department approval.
3. I 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. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
5. I also understand that I/we 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.
I have read and agree to the above:
PRINT NAME: 01,11Q 6
SIGNATURE DATE: 45AVYD
Addition/Alteration Application Revised February 2019