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application Office Use Only ADDITION/ALTERATION PERMIT Permit#: C — © C` 70/ APPLICATION Permit Fee:$ qtZ Town of Queensbury 742 Bay Road,Queensbury,NY 12804 Invoice#: )S 7 P:518-761-8256 www.queensbury.net Project Location: '75-C Z#:` ( 7) W ( �- �, cc E-F \v) �I Tax Map ID #: 506, W-1 Subdivision Name: LI CONTACT INFORMATION: TOWN OF OUEENSBURY • Applicant: SUI►DING&CODES Name(s): 1 C-Ut- cO& W-00 (a/•4 Mailing Address, C/S/Z: 7eite Sr, RCN-€-Av&-arrckbY AP( /730(a Cell Phone: ( S70 ) '--S739 Land Line: ( 51 :3 ) 35-Zo"`f4 Email: P/1-1 fct `' poc2OWS 4 4 0p, 60/4, • Primary Owner(s): Name(s): ()P U tl p por gy+ Mailing Address, C/S/Z: Po ezx A C'`Di Cs i'J'( tZL&.-1 Cell Phone: ( 5'LQ_)) 85`/-- 155 c Land Line: ( ) l Email: t oclr ,,4LLTE(c-Ed\1E-G�C,Y- 600 • Contractor(s): Business Name: •1 e LU/ CON4(16r(1p -4 -i2' Contact Name(s): -(` (C - lifiV)leVt'i44 Mailing Address, C/S/Z: 711P 430 0eZ I ' ST vCLf�N �' N i (2-` ` (.c' Cell Phone: (qb ) S Z€-3731 Land Line: ( 5733 ) 351a-- 1`��S Email: -(Ct� Pt_.,!-tobo�'oW� _t �/�,,Corr\ • Architect(s)/Engineer(s): Business Name: / DNIA- #t" DESWt ( Ggot. Contact Name(s): POS{TO Mailing Address,C/S/Z: (3 9 V 15W/eS 1--1,E gt-e IOAb LF1Ptev/4 NY /ZG(v5 Cell Phone: ( A ) Land Line: t 5 G8 ) 6298 - A3C'Z, Email: filoA 4 lath-hS I1 /44 U/2&_.6rV1frt L,60 w1 Contact Person for Building & Code Compliance: PArgt6 14-ev)pegnitAd Cell Phone: ( st' ) 5 ~3731 Land Line: (57S ) 35-67 ` t' 35- Email: PPrt72(eK itoD012otcl5K4 12ou fi,doi'tl x Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018 PROJECT INFORMATION: TYPE: 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: 2nd floor: 2nd floor: 3rd floor: 3rd floor: Basement(habitable space): Basement(habitable space): Total square feet: Vi bO° Sf Total square feet: ADDITIONAL PROJECT INFORMATION: 1, Estimated Cost of Construction:$ 0-0e ,.c0 2. If Commercial project,what is the proposed use: JLZ.) P-49c0itA / E76201f/l46Kir 3. Source,of Heat(circle one): 4 Oil Propane Solar Other Fireplaces need a separate Lie Burning Appliances &Chimney Application 4. Are there any structures not shown on the plot plan? YES 60.1— xplain: 5. Are there any easements on the property? YES 60)6. SITE INFORMATION: '' a. What is the dimensions or acreage of the parcel? b. Is this a corner lot? YES ICf c. Will the grade be changed as a result fh construction? YES 0 d. What is the water source? PUBL. PRIVATE WELL e. Is the parcel on SEWER or a PRIVATE SEPTIC system? 9Eut`32- Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018 DECLARATION: I. 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: T`'ot4 LTA(14 1/X SIGNATURE: DATE: il3/1 Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018