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' - ADDITION/ALTERATION PERMIT Permit#: CC-D8 l3— 20Z0
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Town of CZircensGury APPLICATION Permit Fee:$
742 Bay Road,Queensbury;NY 12804 C
Invoice#: 2
P:S18-761-8256 ww[w.gueensbury.net
Project Location: i7Jfew>,+1) . JA &,,is6:�` 6v, /!l
Tax.Map ID#: 2 . 6 ' "53 Subdivision Name:
CONTACT INFORMATION:
• Applicant:. `
Narrle(s): �UGC'•) �C�/�l�(�C.�C� '�:FJ
Mailing Address, C/S/Z: ' Cj- G easo,fie- Z.,o 79. .
Cell Phone: ) 1-7 r3. Land Line: A. DS ;99770
Email: .�UHns• Nf��I�SS���s"2D /7c� TGK cyw`
• Primary Owner(s):
Name(s): 5h G✓r!(thms
Mailing Address, C/S/Z: �J3le' (�-/�.✓ Sf SJ�f� /(/ (�Uc� �s h�rt .N `/. fib//
Cell Phone: (,,/jg ) y2 -3SIR v Land-Line:
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): S U"r,3 A-tPy e c
Contractor Trade: (`OAC, 1 Pi
Mailing Address, C/S/Z:
Cell Phone:A2,16 ) i614f?- Cf7,-). Lal6d Line:
Email 4I0..{-tA`I C S S(b533-0 6o-7-4t k, 4crn ,.
"List all additional contractors on the back of this form � -
• Architects)/Eneineer(s):
Buslness Name:
Contact Name(s):
Mailing Address, C/S/Z: vvu�rP tf'
Cell Phone:. ( ) Land Line:
Email:
Contact Person for Building& Code Compliance: ( t�vYc�COn/
Cell-Phone:. Land Line: t )
Email:
Addition/Alteration Application Revised february 20.19
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):
Total square feet: Total-square.feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ uo
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2. If Commercial project,what is the proposed use:�?Q62 .1Jtaysfy:. ; vcrc�i�� +f s
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3. Source of Heat (circle one): Gas 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 0 Explain:
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S. Are there any easements on the property? YES NO
6. SITE INFORMATION:
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a. What is the dimensions or acreage of the parcel? x
b. Is this a corner lot? YES Vb '
c. .Will the grade be changed as a result-gf the construction? YES
d. What is the water source? 0 B L!.C> PRIVATE WELL
e. Is the parcel on SEWEkor a PRIVATE SEPTIC system?
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Addition/Alteration Application Revised February 2019
DECLARATION:
1. 1 acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period.
2. Ifthework is not completed by the 1 year expiration date the permit may be renewed, subject to
fees and department approval.
3. 1 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. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
5. 1 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: �S"U�4i ) �-JPr
SIGNATURE: DATE:
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Addition/Alteration Application Revised February 2019