application • Office Use Only
" ADDITION/ALTERATION PERMIT
Permit#:
APPLICATION Permit Fee: $ 160
Gnrn of(�eensbun
742 Bay Road,Queensbury, NY 12804 Invoice#: a ��
P:518-761-8256 www.gueens�lbury.net
Project Location: 3.).? l'►Vie-moll✓ /zo
Tax Map ID #: 2plID� • Q - \ Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): A4icj44e_L �,--Lad
Mailing Address, C/S/Z: 3_-13 4,,ItoMod ?—eZ'
Cell Phone: ( Y'(J? ) 7 4q - r`fyo Land Line:
Email: /n 8ttE4/1&„ -c-k e- Yoko .C4',
Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Contractor(s): °r i! i
Business Name:
Contact Name(s): C A 4
Mailing Address, C/S/Z:
Cell Phone: Land Line: � )
Email:
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: �_) Land Line: � )
Email:
Contact Person for Building & Code Compliance:
Cell Phone: Land Line:
Email:
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial J_� 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:
4th floor: 4th floor:
Total square feet: fO Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ Q1000
2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one):qFue
Oil Propane Solar Other
Fireplaces need a separateurning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? YES NO Explain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensionso eage of the parcel? '4C.b. Is this a corner lot? YES NO
c. Will the grade be changed as a result ofibe construction? YES NO
d. What is the water source? PUBLIC , PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? .9E,-3.'t-7 C.
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017
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. If thework 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: N1I,cu4E.L- i�2uI
SIGNATURE: k_ DATE: (oW17
I
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017