RC-0305-2020 % t • ,
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Office Use Only
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i ADDITION/ALTERATION PERMIT Permit#: 2-C.-'O.645 -20.2a)
APPLICATION Permit Fee:$ 210
Town ofQueensbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.queensbury.net
Project Location: /1 13 ri C)( INN KJ _
Tax Map ID#: Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): 4(r- 7 L O sj er GGN
Mailing Address, C/S/Z: 1.1 3r c/ o ue/N Rd . C oee/ l3or a 12 S '..7
Cell Phone: (3 1 ) 522 6- Land Line: ( ) Y
Email: l4 Lon G,- an RV- V •� ;,M� I. CO11
• Primary Owner(s): (1I
Name(s): H G r ri S L. 0/4 e rgaiV
Mailing Address C/S/Z: 1 J bra ek dlle/k] lid' ("c�eeN5bory fir L ?o
Cell Phone: ( (��7 ) 6-, 5 . Q. Land Line: ( )
Email: 1 LO4Crgail 61 l( I d m4,,, E CoM
Of Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be sub i Ow- his.application
Contact Name(s): i ii `/a , ,�,
Contractor Trade: ` l f
Mailing Address, C/S/Z: JUN 19 2023 1
Cell Phone: ( ) Land Line: ( ) T
Email: Lit] n Qt?ECf�!s.F lJ�,
**List all additional contractors on the back of this form �` -�`�'�0 =s t�!
• Architect(s)/Engineer(s):
Business Name: 53 eri li x e ei' liv 1 1 G t, L
Contact Name(s): SGO.-f4 V r(', 1 vie.
Mailing Address, C/S/Z: 0 a 4- /V( G`i4-''dr l t/A'k 'Vy /2'
Cell Phone:_.( ) 7/ 4 33 Land Line: ( )
Email: SC o.� 0 8r'.yiii e'1-111)14, c fP1
Contact Person for(3y�Buildi) &Code Compliance: /h ro II G9/lf'p��ldiil
Cell Phone: 51, - 3--- go.. . Land/Line: �_)
Email: r, L pnl erC pip) all j /-J -I 14111 $ CO ii ;
Addition/Alteration Application Revised February 2019
f • ii
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
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:
1st floor: 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement(habitable space): Basement(habitable space): 706
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION: /;
1. Estimated Cost of Construction:$ 00 00
50
2. If Commercial project, what is the proposed use:
3. Source of Heat(circle one): Oil Propane Solar Other
Fireplaces need a separate Fue Burning Appliances&Chimney Application
4. Are there any structures not shown on the plot plan? YES 0 Explain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the •a cel? �3
b. Is this a corner lot?. YES NO
c. Will the grade be changed as a result • le construction? YES NO)
d. What is the water source? PUBLIC PRIVAT WELL t
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? fri''VQTI° (Se c
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: Harm
SIGNATURE: 444/ DATE: 6✓ !, 'a ao
Addition/Alteration Application Revised February 2019