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ADDITION/ALTERATION PERMIT Permit#: W--C`-$- 20 ?rc
® APPLICATION
Permit Fee:$
Town ofQuccnsbury
742 Bay Road,Queensbury,NY 12804 tDPD-1
Invoice#:
P:518-761-8256 www.gueensbury.net
Project Location: M9 1`�A`( TU _ Lc,`(e C-r ed�r-1 e, 'v , 2L$1'S
Tax Map ID#: Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): Gr�_Ra�c,r. Loader _ S�e��a•,�•c �iegvt�
Mailing Address, C/S/Z: I 'PL . ye C,co rc c, h)y t? S46
Cell Phone: lolltr )yo�lf2h-Loq� Pkc40, ,1.703-- Land Line: . ( AAA, )
Email: 1004-cVcA Q 4OL. Cot1� IUn
Primary Owner(s):
Name(s): 5-k-echu &r A` CoL-i
Mailing Address, C/S/Z: '13Aq P.A. Lair- C e L)
Cell Phone: ( 5 10 )'903—(45-7 Land Line: N Ip► )
Email: I ogee[A A yc • EOM
Check 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 for
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• Architect(s)/Enaineer(s): D CIE UV
Business Name: n r"P '�""n
Contact Name(s): UU
Mailing Address, C/S/Z: TOWN OF QUEENSBURY
Cell Phone: Land Line: A
Email:
Contact Person for Building & Code Compliance: V ley
Cell Phone: Land Line:
Email:
Addition/Alteration Application Revised February 2019
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PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
V( Single-Family _Two-Family _Multi-Family(#of units )
_Townhouse Business Office _ Retail
Industrial Warehouse v Gara e #of cars Other describe
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 0 ^ 1st floor: 2Z3,Z 3
2nd floor: 0 2nd floor: — O "
31 floor: 9A 3rd floor:
Basement(habitable space): N Basement(habitable space): tJ
Total square feet: %. 0 .r Total square feet:
ADDITIONAL PROJECT INFORMATION:
00
1. Estimated Cost of Construction: $ y.0D�
2. If Commercial project,what is the proposed use:
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 RExplain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the arcel? a�
b. Is this a corner lot? YES 00
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? IC PRIVATE WEL
e. Is the parcel on SEWER or a PRIVATE SEPTI ystem?
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
�ewlYcons�true d facilities prior to issuance of a certificate of occupancy.
Hoke: Ov'v4lVc r 1 INbr v a
I have read and agree to the above:
PRINT NAME: e e et- S4, nk\ajue l ie �, C
SIGNATURE: r� DATE:
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Addition/Alteration Application Revised February 2019