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application Office Use Only ADDITION/ALTERATION PERMIT Permit#: 24C 0040 . 2Q lPo APPLICATION Permit Fee:$ 76nv11 of Queensbun 742 Bay Road,Queensbury,NY 12804 Invoice#: d© P:518-761-8256 www.gueensburV.net Project Location: y� 1,�,1�f /280 J/ Tax Map ID#: 2(3 �J 5 ' Subdivision Name: CONTACT INFORMATION: • Applicant: Name(s): _'417- " Mailing Address, C/S/Z: 1,21,, e Cell Phone: r1i ) 7sx-, .p` Land Line: Email: Primary Owner(s): Name(s): b lei ,cam e io�e'r- /-zC. Mailing Address, C/S/Z: S0 &e_✓ At. Cell Phone: S-,X ) 751/ - tea Land Line: � ) Email: 4'a,r4 j (j-y e ���a ' . w , • Contractor(s): Business Name: Contact Name(s): Mailing Address, C/S/Z: Cell Phone: Land Line: Email: FEB 0 1 2018 • Arch itect(s)/Engineer(s): -- Business Name: TOWN OF QUEENSBURY Contact Name(s): Mailing Address, C/S/Z: Cell Phone: Land Line: Email: Contact Person for Building & Code Compliance: /0"4/ Cell Phone: ( !(71 ) 79/ -Iaa/ Land Line: Email: /.ry 0 r•-19#1C. w n+ Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017 ` t PROJECT INFORMATION: TYPE: Commercial Residential WO 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: �l/ /,-?,)Z-e' 1st floor: 2"d floor: 2nd floor: 3rd floor: 3rd floor: 4th floor: 4th floor: Total square feet: -72 — Total square feet: •� ��• ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ /`" 'd>are 2. If Commercial project, what is the proposed use: 3. Source of Heat (circle one):CGa Oil Propane Solar Other Fireplaces need a separaterning Appliances & Chimney Application 4. Are there any structures not shown on the plot plan? YES eNO xplain: 5. Are there any easements on the property? YES 6. SITE INFORMATION: //,/, vJf r3/hk� elve r^.fC ., f a. What is the dimensions or acreage of the p rcel? /,', et b. Is this a corner lot? YES O c. Will the grade be changed as a res a construction? YES NO" d. What is the water source? :PUBLIC ; PRIVATE?eL,.Lle e. Is the parcel on SEWER or a PRIVATE SEPTIC system? P Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017 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. S. 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 agreIte above: PRINT NAME: SIGNATUR DATE: Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017