application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: CC -' - 2o1e)
APPLICATION Permit Fee:$ - 20
form of(Lw c'tt l=un
742 Bay Road,Queensbury,NY 12804 Invoice#: D
P:518-761-8256 www.queensbury.net p
Project Location: ��7 3 0 L�C.k A / 2! 41 l /�d1 .m. •a..,. . __..._
EEO �l
Tax Map ID #: Subdivision Name: U I
_ N _ . 1 APR 25 2018 fLJ
CONTACT INFORMATION:; TOWN OF QUEEi SBURY
BUILDING& CODES
• Applicant:
Name(s): R
Mailing Address, C/S/Z: 3 Oe e 2,4 ry Rcj 4i cc- C06o 9 L/ / 2''f C
Cell Phone: ( ) . 1 8 P- 3 r7 I 1-7 Land Line: ( B ) CP B 9 4 S S
Email: -/• clo-i-l-ri C61) hycap, rr: LoPv)
• Primary Owner(s):
Name(s): /fly //irt S C n r c / , Z. )n,iv l u e ?Ete
Mailing Address, C/S/Z: PO Sc 6 / L.4tc CC-vre E /lJi" / ? `/5
Cell Phone: 15/'(e ) `i7 3 3 c3 3 Land Line: I_ 5/ (e) 9 r1 / r7 9 '7
Email: elrY-a / 0 /e i vi f / • cowl
• Contractor(s):
Business Name: L. 'c6. 3 i OE Coin=s 7 2u Cr, 0(L)
Contact Name(s): £P N De_ A i c(\-
MailingAddress, C/S/Z: 471CP Cofh "Qv✓i<44. biz L. e-66-c 5eA)rr iaPgs
Cell Phone: ( 5 r B) j `-7' `/ 4/ `7` Land Line: ( / e ) 6 8 Y 'i" 8
Email:
• Architect(s)/Engineer(s):
Business Name: G . Pe eevS ew
Contact Name(s): 5e ru S—ry
Mailing Address, C/S/Z: / `T C L) es r- f e SG, C. /e/ss e o 5
Cell Phone: ( ) Land Line: ( S g ) r7 mot' B 3 B $ 7
Email:
Contact Person for Building & Code Compliance: A-LF ee-
Cell Phone: ( #.5/8) G23 7,)-1 Land Line: ( �i e ) 6 (p e 94, 5-3
Email: *e%o -h ; �� v y ee- p c V� � c o .n
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
_Single-Family Two-Family Multi-Family(#of units )
Townhouse Business Office Retail/
Industrial/Warehouse b Garage (#of cars ! ) _Other(describe
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: a, 3014 1st floor:
2"d floor: 2"d floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: at 3 0 '1 Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ d 5 cD OCO
2. If Commercial project, what is the proposed use: ( Qv- 54erq,p
3. Source of Heat (circle one): Gas Oil Propan Solar Other
Fireplaces need a separate Fuel Burning App races&Chimney Application
4. Are there any structures not shown on the plot plan? YES NO ,y plain:
S. Are there any easements on the property? NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? (9,55
b. Is this a corner lot? YES ( NO
c. Will the grade be changed as a result of the-construction? YES 6, NO
d. What is the water source? BLIC . PRIVATE WELL g u I+ 2 tO Ph IA) &6Ike-1—
e. Is the parcel on SEWER or PRIVATE SEPTIC ystem? w A-"re c.00 l "o
DEC>' AT1oN:
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 l/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: Di ALA y\ Go- melier2 ° ye`')F Pc / i S, c-la-13 c/Q5
SIGNATU �I�,� �� _ DATE: / / 6/ / 8