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application 14 I Office Use Only i ,f r; ADDITION/ALTERATION PERMIT Permit;:Re 35D le � .�,. �t ' ; • APPLICATION Permit Fee: $�, I �----- Town of 0`eensbuiy _ 742 Bay Road,Queensbury,NY 12804 Invoice t: 5-D. P:518-761-8256 www.queensburv.net Project Location: 1( I` . . 0/! Rd...--- �`-e ,,,,i-- G� l�3 o��j I � 4 ,, Tax Map ID ##: 4- ., / •-/`f SubdivisianL a€:[ 0 V 0 n i .;-: I— 11 CONTACT INFORMATION: R iU,M 3 `D'ri, p O Applicant: !, ': .IEENSBURY Name(s): ikm�c�d.0 L � L2�44-(E _ Mailing Address, C/S/z '7 'D l r21ji C Pt, at 10 . 0( t 2 g.O`i Cell Phone: ( t. ) a7 ILs-`7 Z Land Line: ( C1 (V ) cao-a 0 t '7 Email: AD, Lei-( e 341,00 , co dA • Primary Owner(s): S � � p Name(s): ,6.y' o . Li' 1A - ed4goiY Mailing Address, C/S/Z: _7 ?i ce IA, i, %-5 1 V fZ,F') 11 Cell Phone: ( :} ( y ) q 7 I S�Z Land Line: ( I W - ) 00? 0($7 Email: Gut ( fi e ,..,, 4, o Contractor(q: (bo, . Business Name: - L� I- 6d (C -, 5`--",--1/© ContactName(s): N 0A- - �2 ��a Mailing Address, C/S/Z: 2' c c C1-. (4 \ Y(1 s Mr/Y 17 ` Cell Phone: ( i ) '3069 I t3 3 Land Line: ( ) Email: \ i it r<, kfizo&61.05 qix G co e__ GV a.,.( ic.p. • 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: j &A3 l 0/ Cell Phone: . c-VV ) 113 and Line: ( ) Email: w1 ev d 41 ar(),0 4rem s4 ` i ( - eo 1.Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018 PROJECT INFORMATION: TYPE: Commercial 1/( 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: 9 0 0 2nd floor: 2nd floor: 3rd floor: 3rd floor' Basement (habitable space): • Basement (habitable space)` Total square feet: Total square feet: / d 0 • ADDITIONAL PROJECT INFORMATION: 1. . Estimated Cost of Construction: $ I CI ©ca 2. If Commercial project, what is the proposed use: 3. Source of Heat (circle one): Gas Oil Propane Solar et i L (C c 'C Fireplaces need a separate Fuel Burning 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 0 6. SITE INFORMATION: a. What is the dimensions or acreage of the arcel? I - � b. Is this a corner lot? YES460 c. Will the grade be changed as a result o o +c . YES f D d. What is the water source? PUBLIC PRIVATE L e. Is the parcel on SEWER or a PRIVATE SEPTIC system. • • • • Town of Queensbury Building&Code Enforcement - Addition/Alteration Application Revised March 2018 t , I DECLARATION: • 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: 4161C-6 L&cLcL SIGNATURE: DATE: I lki g • • • • • • • Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018