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RC-0757-2019
Office Use Only|permitd:/RC~O75 7-C617 Permit Fi es eee 4\25. invoice st eer 22\erTownofQueensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Project Location:|Tax Map ID #:_30]./2-/-2)Re 000 250-2e/4 Subdivision Name:_CypeGreen CONTACT INFORMATION: ©Applicant:+...é Name(s):Take ond Lecgh _/4esr¥on Mailing Address,C/S/Z:__QQ Hele Drive Coby wy la%ey Cell Phone:_(S'&_)_302-/7$o land Line:_() Email: +Primary Owner(s): Name(s):Sak?ard Leigh ensea Mailing Address,C/S/Z:__22 /#zp Dive Gey NY 1d 5O5 Cell Phone:(S1%_)302-17 bo Land Line:_() Email:_Jakek @ Kp:Seute-Gn Legh St hive~Gon O Check if all work will be performed by homeowner only ©Contractor(s):Workers’Comp documentation must be submitted with this application Contact Name(s):__(Yeo View Viele Condeachng ) Contractor Trade:o-Ps teMailingAddress,C/S/2:_//Be Rum Cranseveoce MY 19-837 Cell Phone:(S7¥_)__PSS=O8S,land Line:_(S7¥_)_29-220 4 Email:__Viele (botacting @ Apl.Go-r *#List all additional contractors on the back of this form ©Architect(s)/Engineer(s): Business Name: Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance:__(“4B We /c Cell Phone:(SI¥_)_95 S-o $77 Land Line:_() Email:(A¢/7Gatectir-y @ Av.Go ‘Addition/Alteration Application Rewsed February 2018 JECT INFORMATION:PRO. Commercial x ResidentialTYPE: ‘WORK CLASS: MX single-Family __Two-Family ___Multi-Family (#of units ) __Townhouse ___Business Office __Retail __Industrial/Warehouse __Garage (tf of cars )—_Other (describe Zot ) ADDITION SQUARE FOOTAGE:ALTERATION SQUARE FOOTAGE: Zoe Basement (habitable space):Basement (habitable space} Total square feet:Zo Dro Size.Zbx HY Total square feet: ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$~_/'7 30000 2.If Commercial project,what is the proposed use: 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 wo)Explain: 5,Are there any easements on the property?YES 6.SITE INFORMATION:y.78.0a.What Is the dimensions or acreage of theparcel?_/75.5%%155.87 % b.Is this a corner lot?YES:NO) c.Will the grade be changed as a result of the construction?YES (x9 d.What is the water source?LIC PRIVATE WELL e.Is the parcel on SEWER or a PRIVATE SEPTIC system? __ Seah ‘Additlon/Alteration Application Revised February 2019 DECLARATION: 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 thework is not completed by the 1 year expiration date the permit may be renewed,subject to fees and department approval 3.|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.|acknowledge that prior to occupying the facilities proposed |,or my agents,will obtain a certificate of occupancy, 5.lalsounderstand 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. Ihave read and agree to the above: CHa /le SIGNATURE:ld ~~DATE:_//-12-/7 PRINT NAME: ‘Additian/Alteration Application Revised February 2018 2013|NOV 19 BUILDING &CO! ECEIVE TOWN OF QUI i C5 SET 26208 Gonisnr may has -2 poste by A cae omy 19d areas Deed een), Boymajony Dia zyme? eee: 208 s.f. RC-0757-2019 igh4@qa daaweeigsgai825B2a8