application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: �,. OE)kar ' 2-C>tci
APPLICATION Permit Fee: $ 2-Crt
Timis UI Quccmhtio
742 Bay Road,Queensbury,NY 12804 Invoice#: 12.2?b
P:518-761-8256 www.queensburv.net
Project Location: 5b4YiCan
Tax Map ID #: Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): 3vr4ifi `T xy L-/o S rzder uKei CAA -- (evtb't' th vt € 4i 4Cs
Mailing Address, C/S/Z: .P 1; Eck 70 ; ?''5 ) Ztt , Y,tr,it 1H is , N y
Cell Phone: ( 18 ) 6,5'7 tS- Land Line: ( 57 ' ) 3' '(-i6S/
Email: der Sat t t r`�j,td CC cc
• Primary Owner(s):
Name(s): Zbev 1- Et 17-144e4. Gt Le,/ L,-
Mailing Address, C/S/Z: 2i0 try* Ic R4 ,„: , N.T 0 7'tSZ
Cell Phone: (2Ti ) 47 `i27S ( 344) ) Land Line: (ZL t ) (Liz)
Email: - wN Vey► zn.riet-
• Contractor(s):
Business Name: Sdh L V a 6144pAit ,-- Seevi4S
Contact Name(s): 'gept .ergsiCi-60)
Mailing Address, C/S/Z: 'Po . '7G , fcrt2 . Etr#-
Cell Phone: ( ) Land Line: ( 51f3 ) 3eiei-/e) 1
Email: 624 l! "(lee ",.^�
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s): / Y1&ti w (v✓ho44- (r%ek Nrcit'kyf- ` 031124 r'ys)
Mailing Address, C/S/Z: 222 Lark Sf. s t2-3c
Cell Phone: ( 516 ) '7PS - 4411 Land Line: (
Email:
Contact Person for Building & Code Compliance: dnfiPf✓v
Cell Phone: ( ) Land Line: ( ) (
Email: :r►('ri & 5c,bh ti hedge,afn
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: '2
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement(habitable space): Basement (habitable space):
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ }75 (iOU r
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 CO Explain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel?
b. Is this a corner lot? YES NO
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 PRIVATE SEPTIC system?
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
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.
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 kb
SIGNATURE:
DATE: Z/S/I`/
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018