application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: C C - 0 .)-ci7-70(
APPLICATION Permit Fee: $ (e'6 I ? C)C
T sn ofQueensbur} _
742 Bay Road,Queensbury,NY 12804 Invoice #:
P: 518-761-8256 www.queensbury.net
Project Location: - Qfe.plaill. '54
Tax Map ID #: ' 4111 ' " ad siB*
OoL. -1-21-
CONTACT INFORMATION: MAY 1 3 2019
• Applicant: TOWN OF QUEENSBURY
Name(s): �L72w,c�O" Y IR. BUILDING&CODES
Mailing Address, C/S/Z: Z' 5 Z€e- - 5z.� 1 , .,��i, 0(007I
Cell Phone: ( g(pb ) 647 Z -c161t Land Line: ( rk. ' ) Zc,0 - Z51rci f -I- JZZ
Email: rz,,,.c n AU;
• Primary Owner(s):
Name(s): Atd
Mailing Address, C/S/Z: 'Z55 "ltd. 5+ S�>..t �;.%�oet5cw C f)('b')
Cell Phone: Sjobs ) ( I - '-/511 Land Line: ( n ) Z`27()— Z CX) I ZZ.
Email: �n� 114 �c� �lc_;..
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): (7.t 3
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): nb
Mailing Address, C/S/Z: ii5 15h0..'-S La,., Utc {-2x.. kik/ r4s u �
Cell Phone: ( ) Land Line: ( SF35 ) 771Z- Z Z
Email:
Contact Person for Building & Code Compliance: TaC, Cv \I� LL
Cell Phone: ( ) Land Line: (
Email:
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: y Commercial 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: 2_Z-1 �=
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: 2.2 agn
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 2., 050 OCJ
2. If Commercial project, what is the proposed use: Clcbc.. .C1
3. Source of Heat (circle one): £ 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 Explain:
5. Are there any easements on the property? YES 4D
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel?
b. Is this a corner lot? YES
c. Will the grade be changed as a result of the construction? YES
d. What is the water .:.- ce? PUBLI PRIVATE WELL
e. Is the parcel on ; or a PRIVATE SEPTIC system?
Addition/Alteration Application Revised February 2019