application Office Use Only
4t/r" ADDITION/ALT pL� it#: CC () 2 U 1
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APPLI C I N P t Fee: $ ��5
lown ofQuccnsbun
742 Bay Road,Queensbury,NY 12804 MAY 0 6 2019 in I e#: '?`'r jl
P:518-761-8256 www.queensbury.net
TOWN OF QUEENSBURY - /
Project Location: G LEKI Floor, c B LDING & CODES
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Tax Map ID #: 2-9G • 11 -1 42- Subdivision Name: N(°'
CONTACT INFORMATION:
• Applicant:Name(s): B L (_nN5rt2..vc_nat.t C/O 612-€1c r& ' Yo(-2r-teMS
Mailing Address, C/S/Z: Sot__ \ S tN \r AvE_E"�l loaiy mil`/ 12263
Cell Phone: ( S lg ) 49 l- ( 1•+O Land Line: ( ) /4S2- 3200
Email: G-cyOUHdN.S p laaLtNJC. CoM•
• Primary Owner(s):
Name(s): CloDtcno -1S t2-P S,EJ,-pry cD )t_ . I 1,1c
Mailing Address, C/S/Z: C,4-e7T y A.vE , ,4.1116-1-ty 7,4y
Cell Phone: ( ) Land Line: (5t8 ) ljt',r - &r10
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): sQo
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: he p 42cta 1T ELTS
Contact Name(s): Jtv.-, Cc)(c
Mailing Address, C/S/Z: 302_ 14.)d sr4 t Nc -r1,.1 A (E {• Al toer,a‘it N �! 12203
Cell Phone: ( ) Land Line: ( SIBS ) 452-g20O
Email: c kkdCP< e5111,) • C_oM
Contact Person for Building & Code Compliance: gc oca / yocsrM,dn.t_S
Cell Phone: ( Si% ) - 'R k - CpgtO Land Line: ( Si' )llf '-R•SZ-gtbo
Email: Ca:Yo S @ t3t3 L- & ► C.( tvt
4 Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: X Commercial Residential
WORK CLASS:
Single-Family Two-Family Multi-Family (# of units
Townhouse Business Office Retail
Industrial/Warehouse Garage (#of cars ) X Other (describe i3° D "4-9
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor: 4,200
2nd floor: 2"d floor: 4, 200
3rd floor: 3rd floor: rn+/A
Basement (habitable space): Basement (habitable space): t4(A4
Total square feet: Total square feet: 3,400 sF
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ I (00, COO. °-
2. If Commercial project, what is the proposed use: RL�ciert,4.I Ad c)-to F..ad Ty.
3. Source of Heat (circle one): alkOil Propane Solar Other
Fireplaces need a separate Fue Burning Appliances & Chimney Application
4. Are there any structures not shown on the plot plan? ES NO Explain: small I00Sc S4IED
S. Are there any easements on the property? NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? • 9 6 AC¢CA
b. Is this a corner lot? YES
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? PUBLIC PRIVATE WELL
)
e. Is the parcel on SEWER or a PRIVA PTIC system? 5eGJe-e-,
Addition/Alteration Application Revised February 2019
A I.
DECLARATION:
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. / r.
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. Air
4. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy. Ay
5. I also understand that I/we are required to provide an as-built survey by a licensed land surveyor of all
4 newly constructed facilities prior to issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: 1I - ctorL., `at.-'r-%A.NS
SIGNATURE:6 a DATE: 4I2.411c1
Addition/Alteration Application Revised February 2019