application Office Use OnI
ADDITION/ALTERATION PERMIT Permit#: 1]P'�(L�,
APPLICATION Permit Fee:$�. (a0
Town of Qi ensbtiry
742 Bay Road,Queensbury,NY 12804 Invoice#: LC —7
P:518-761-8256 www.gueensbury.net
Project Location: (J 5_ ht-akft -
Tax Map ID#: Z2'� . 13 - Z-30 Subdivision Name: ---
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CONTACT INFORMATION:
• Applicant: DEC 042018
Name(s): M a_r P cb!)),n TOWN OF OUEENSBURY
Mailing Address, C/S/i PD b(x A5m COMNIUNI`Y
Cell Phone: 21 ) 21b) - 451T Land Line: � )
Email: Mtkru . N�LLD,,\,n i r;o)t.Nr I� nU,n7,>1L. wrn
• Primary Owner(s):
Name(s): Ktvl j t-\LMt1in
Mailing Address, C/S/Z: 9 Q f)(N 45W a1ALl,619U f . N\ 12�p4
Cell Phone: ( 311 ) 1 - Land Line: 1_)
Email: FAtV i A, Tr �1i/? n
• Contractor(s)••
p �
Business Name: Ci�unL L to IfUL�I�I►�l
Contact Name(s): MGt�-I Li�cXtL
Mailing Address, C/S/Z: PO x I,1?�A , (-II um Rol") W� 1220
Cell Phone: 51 ) qQ 2- g Z 42 Land Line:
Email: IACi L c� Ci�cx-iy. (LAY)
• Architect(s)/Engineer(s):
Business Name: AW: Atrr LI W " Qt,;)iGf)
Contact Name(s): 06AA 0' Amur(_
Mailing Address, C/S/Z: 112 iri d- xi k IU Guf'GJ6 tA S rin 5 MY 1 MAP
Cell Phone: ) Land Line: ( Sly 33Z- r3 A
Email: QO I 1�C1 - OLt i�LL�-u fL . CUYY1
0
Contact Person for Building& Code Compliance:
Cell Phone: Jand Line: TU
Email:
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
PROJ E&I N FORMATION:
TYPE: Commercial X 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: ` 4
2nd floor: 2nd floor: I Z�)
3rd floor: 3rd floor:
Basement (habitable space): Basement(habitable space):
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $U J . LW
2. If Commercial project,what is the proposed use:
3. Source of Heat (circle one): Gas Oil 0Propane Solar Other
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 NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the rcel? 0 ,(Xn X-CUb
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? PUBLIC RIVATE WE
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Pi Ji QA. L C_
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
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 the work 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: S
SIGNATURE: -� DATE: l-Z V3
Town of 4ueensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
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