application s
Office Use Only
• Y ADDITION/ALTERATION PERMIT Permit#: as-o Q Or ZQ�
\tip APPLICATION Permit Fee:$ i5�•80
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.queensbury.net
Project Location: r207‘ ,84/ .44 aegis
Tax Map ID #: QO�e iq" '/ �f Subdivisio ie: !
OCT 052020 [:�
CONTACT INFORMATION: _�
TOWN OF QUEENS 1iR
• A li ant/ BUILDING& C g. FS
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Name(s): 1,'� � &-eftri;%/1
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Mailing Address, C/S/Z: 663 a ftlj t'I /a/ 1 %-" r ted iaiyso
Cell Phone: ) 592t,/�� Land Line: ( )
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Email: Iteco I a �61-v►
• Primary Owner(s):
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Name(s): �/1'T /1,4n,Fp(4�/11 .�f172, //A,W 6)Mailing Address, C/S/Z: 702C /bilk (9 i 'f..3Lf.4� ,. ,' /21-e
Cell Phone: ( � ) - > Land Line: ( )
Email: aelOYp 4' 4D/,-
❑ Check if all work will be performed by homeowner only
• Contractor(s) Workers' Comp documentation must be submitted with this application
Contact Name(s): t Cs atc,45:✓
Contractor Trade: ( L ) U/ ifS' j`ir', �i1�/r
Mailing Address, C/S/Z: ���� ,1,° �( 4'l )L �ypfievritry
�; /9/'a 442(dg/" .77,269,
Cell Phone: (' /1 Land Line: )
Email: 67,m Liz y//i/ �/��►
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: lL fiJ'STty-S
Contact Name(s): g-e- //f75:-.4 _
Mailing Address, C/S/Z: ' 307 4-T*/ .4/J, ,D,DI�f o,9i>U/f,41 /4. 1)119/!2 4101/67.
,lsy.f61r,1
Cell Phone: ) ``� 7 -- 37q Land Line: ( )
Email: if LIic141J7 4-OL. re/4
Contact Person forB'aiid4Rg-&-Cade Com• '- • -: yorvliir'rhtra is ' •'61‘ J1
Cell Phone: ► .yiii: ~ Lancrttrre
Email: I;aWIi 1A 1i. . A
I . _
Addition/Alteration Application Revised February 2019
S
PROJECT INFORMATION:
TYPE: / Commercial Residential
WORK CLASS:
Single-Family _Two-Family _Multi-Family(#of units )
Townhouse x Business Office _Retail
Industrial/Warehouse _Garage (#of cars ) _Other(describe )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor: I4' C
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement(habitable space): Basement(habitable space): /
Total square feet: Total square feet: /4/rj 6
ADDITIONAL PROJECT INFORMATION: //
1. Estimated Cost of Construction: $ <e 00
2. If Commercial project, what is the proposed use: 4:///J/df eQele (1/427 //c/O t/4 6��-6.
3. Source of Heat (circle one): Gas 0 Propane Solar Other
Fireplaces need a separate Fuel Burning Appliances&Chimney Application
4. Are there any structures not shown on the plot plan? YES 1.Explain:
_5. Are there any easements on the property? YES NO
6. SITE INFORMATION: h
a. What is the dimensions or acreage of the parcel? )40 f 7 / 7 0 Fl
b. Is this a corner lot? YES
c. Will the grade be changed as a resul • the construction? YES N
d. What is the wat-. • e? r'UBL • PRIVATE WELL
e. Is the parcel o� ., f'•r . IVATE SEPT system?
Addition/Alteration Application Revised February 2019
z
DECLARATION:
0
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: (,A6/Gn 94,---cAl
-7 SIGNATURE: - DATE: 7/3 ,,,e,,,,,,,
Addition/Alteration Application Revised February 2019