application i„e Use Only
' 01iADDITION/Arlo rmit#: C C - t 7�2 �y
�:> APPFI; Id1EC 1 1 2018 rmit Fee:$ 2 sue(. 50
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742 Bay Road,Queensbury,NY 12804 ( (Z
TOWN 01= '�s�IEENSBt1RNnvc ice#: 1
P:518-761-8256 www.queensbury.net BUILDING&CODES
Project Location: il"
Tax Map ID #: Z 16' . r S 1—. ' Subdivision Name: -Ark A ti,
CONTACT INFORMATION:
• Applicant: /"
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Name(s): (� QCAs4&-
Mailin Address, C/S/Z: ").1,�6( �c� h-�- (& ( i�tv° l t f`'C`( ( c-((1
Cell Phone: ( Pa, ) 3 Li 5 — 01--1 Land Line: ( )
Email: V LV\AreA, CAA')eVtiv'1 L,Ji 4-G ni--k , rCk \
• Primary Owner(s):
Name(s): clANNIC Fir C,L)C
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
• Contractor(s):
Business Name: li-P ec,.,\\ 5
Contact Name(s): " ruin,i'S ►C.(<
Mailing Address, C/S/Z:
Cell Phone: ( S'(v ) 71 S 1 c Lk, Land Line: ( )
Email:
• Architect(s)/Engineer(s): 1
Business Name: 1'1 b f-4 rc, ))A-f'c� •G -�
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Contact Name(s): t�k \ t.. t., t'
Mailing Address, C/S/Z: 'c."';' ( L;?(-, c.-1
Cell Phone: ( jIS/ ) Lt'a,CA. tf�C.) CL 3 Land Line: ( )
Email: ' 'Ir) ' Cii...fit) bc%x(._:r ` �c.- --&rz.-- 4 Ci 0.1'11
Contact Person for Building & Code Compliance: (111c�6'
Cell Phone: (37= . IN r'-7C1,0t-1 Land Line: ( )
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Email:Ytci1tc r°ik 'l 14'103= tiari i ,, (-1,'
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Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
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PROJECT INFORMATION:
TYPE: N 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: S
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: 24'F�Sf
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ I 5
2. If Commercial project, what is the proposed use: 'R I. \ � ;-y, 't)e-4�,�
3. Source of Heat (circle one): Gas) 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 NO xplain:
5. Are there any easements on the property? YES CI710)f
6. SITE INFORMATION:
a. What is the dimensions or acreage of th rcel.
2 ici
b. Is this a corner lot? YES NC) ,.---
c. Will the grade be changed as a re a construction? YES C1_91
d. What is the water---sce? ('Llf..y.E...3_W PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system?
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
DI'CLARATION:
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: Y\r\ \Ci .\ 11471 .n)
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SIGNATURE: DATE: t
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018