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application Office Use Only ADDITION/ALTERATION PERMIT Permit#: CS„�" O cD "20 va) APPLICATION Town ofQucsbury Permit Fee: $ tr-3 �10 • (00 742 Bay Road,Queensbury, NY 12804 Invoice#: b 0.p265 P: 518-761-8256 www.queensbury.net Project Location: 171 Carey Road, Queensbury, NY Tax Map ID #: 309.13-2-31.2 Subdivision Name: CONTACT INFORMATION: • Applicant: Name(s): Hudson Headwaters Health Network Mailing Address, C/S/Z: 9 Carey Road, Queensbury, NY 12804 Cell Phone: (518) 857-3408 Land Line: (518) 761-0300 x31624 Email: dvalentini@hhhn.org • Primary Owner(s): Name(s): Hudson Headwaters Health Network Mailing Address, C/S/Z: 9 Carey Road, Queensbury, NY 12804 Cell Phone: (518) 857-3408 Land Line: (518) 761-0300 x31624 Email: Dal Valentini <dvalentini@hhhn.org> ❑ Check if all work will be performed by homeowner only • Contractor(s): c E [1 \VE5 Contact Name(s): MLB Construction Services, LLC D Contractor Trade: General Construction JUL 2 4 2019 i Mailing Address, C/S/Z: One Stone Break Road, Malta, NY 12020 - Cell Phone: (518) 857-2520 Land Line: (518) 289-1371 TOWN OF QUEENSBURY Email: Brian Douglass <bdouglass@mlbind.com> BUILDING& CODES **List all additional contractors on the back of this form • Architect(s)/Engineer(s): Business Name: The Architectural Collaborative Contact Name(s): Jonathan Primeau, RA Mailing Address, C/S/Z: PO Box 2046, Wilton, NY 12831 Cell Phone: (518) 796-6236 Land Line: Click or tap here to enter text. Email: jon@thearchitecturalcollaborative.com Contact Person for Building & Code Compliance: Jonathan Primeau,RA Cell Phone: (518) 796-6236 Land Line: Click or tap here to enter text. Email: jon@thearchitecturalcollaborative.com Addition/Alteration Application Revised February 2019 _ PROJECT INFORMATION: TYPE: ❑X Commercial ❑ Residential WORK CLASS: ❑ Single-Family ❑Two-Family ❑Multi-Family (# of units ❑Townhouse ❑X Business Office ❑Retail ❑ Industrial/Warehouse ❑ Garage (#of cars ) ❑ Other (describe ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE: 1st floor: 1st floor: 798 sf 2nd floor: 2nd floor: 0 3rd floor: 3rd floor: 0 Basement (habitable space): Basement (habitable space): 4,434 sf Total square feet: Total square feet: 5,232 sf ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ 735,990 2. If Commercial project, what is the proposed use: Medical Office 3. Source of heat: ❑XGas❑Oil❑Propane❑Solar ❑Other Fireplaces need a separate Fuel Burning Appliances & Chimney Application 4. Are there any structures not shown on the plot plan? DYES LINO Explain: 5. Are there any easements on the property? ©YES ONO 6. SITE INFORMATION: a. What is the dimensions or acreage of the parcel? 6.9 acres b. Is this a corner lot? ®YES LINO c. Will the grade be changed as a result of the construction? OYES ©NO d. What is the water source? ❑X PUBLIC ❑PRIVATE WELL e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Private Septic Addition/Alteration Application Revised February 2019 DECLARATION: I. 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: Dal V Ientini, 0 n r Representative SIGNATURE: DATE: 07-19-2019 Addition/Alteration Application Revised February 2019