application Office Use Only
ADDITION/ALTERATION Permit #: o - Zo 11
IT
c cr i,tsr>it APPLICATION Permit Fee: $ ,� 2-DO
742 Bay Road, Queensbury, NY 12804 Invoice #: �-�
P: 518-761-8256 rv.e •
,. ,..,. ._
Project Location: _26 Oak Valley Way
FECEOVED
Tax Map ID #:74/ . 1- -(A Subdivision Name: _North Forty
MAR 0 7 2019
CONTACT INFORMATION: TOWr+ . ! aj \-r BURY
BUILDING&COOPS
• Applicant:
Name(s): Ted Chrimes
Mailing Address, C/S/Z: 26 Oak Valley Way, Queensbury NY 12804
Cell Phone: _(518) 469-8535 Land Line: _( )
Email: ted.chrimesiii@gmail.com
• Primary Owner(s):
Name(s): Ted Chrimes
Mailing Address, C/S/Z: _26 Oak Valley Way, Queensbury NY 12804
Cell Phone: _( ) Land Line: _( )
Email:
i Check if all work will be performed by homeowner only
• Contractor(s):
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
Contact Person for Building Et Code Compliance: ,(‘. Nv-a,t,,''.--
Cell Phone: ( ) Land Line: _( )
Email:
Addition/Alteration Application Revised February 2019
TYPE: ❑ Commercial X Residential
WORK CLASS:
X 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: JOT. Bonus room
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: _8OO
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ _10,000
2. If Commercial project, what is the proposed use:
3. Source of heat: ❑Gas❑Oil X Propane❑Solar ❑Other Fireplaces need a separate
Fuel Burning Appliances Et Chimney Application
4. Are there any structures not shown on the plot plan? ❑YES X NO Explain:
5. Are there any easements on the property? ❑YES X NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? 2.8 acres
b. Is this a corner lot? ❑YES X NO
c. Will the grade be changed as a result of the construction? ❑YES X NO
d. What is the water source? ❑PUBLIC X PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Septic
DECLARATION:
Addition/Alteration Application Revised February 2019
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 INve 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: Ted Chrim s
SIGNATURE: 0 u DATE: 3 1 1 7
REQUIREMENTS FOR SUBMITTAL:
Addition/Alteration Application Revised February 2019