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application Office Use Only , (7 ADDITION/ALTERATION PERMIT Permit#: �� - 2f3t1 APPLICATION Permit Fee:$ 2_bb te(zwelmigio 742 Bay Road,Queensbury,NY 12804 Invoice#: 12 p cb P:518-761-8256 www.queensbury.net Project Location: //i �l k (Rf dQ.,C \DY. Tax Map ID#: (J/ . /J " U ,,U'`1 Subdivision Name: /k 1 CONTACT INFORMATION: • Applicant: Name(s): kJo 44i?r1) kra-trp'i S C7�neraa CUrrfra.ci LLC Mailing Address, C/S/Z: 58&l.Yaio GL)4'✓, 6o C1tns JS, /lf I/a03 Cell Phone: (oil ) :j (v0 - Iq 78• Land Line: ( 518 ) 7 9g-7y9q Email: T)DY+hetn.e r"S SS&S L1 rntk:l, Conn • Primary Owner's): Name(s): pJ O(..LS Orl 61.er /LI Mailing Address, C/S/Z: /5 Lfkr/;i-dq,Jt( QLLeef1Sbt) rl( NC/ /c gCr4 Cell Phone: ( &17 ) 7 7 - C1 k 77 ,J Land Line: ( Email: I hle t I j O C (neu , CO ❑ Check if all work will be performed by homeowner only • Contractor(s): Workers' Comp documentation must be submitted with this application Contact Name(s): j-ebrq,e is-u-ckw'15 Contractor Trade: COnSI"YU.cif or) Mailing Address, C/S/Z: c3R (SnzQfiColCL 7411e. (') L7f ens -Fails, L / 9 Q3 Cell Phone: (`5 / c ,O -/q7k J Land Line: ( 1(f ) 7`i _7Liqq Email: no(-Hiern.e ichrposes' 7 v toI . (} 0 **List all additional contractrna rs on the back of this form • Architect(s)/Engineer(s):Business Name: \, E © 231WD Contact Name(s): 1i AR 1 Z 3 Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: ) Email: Contact Person for Building & Code Compliance: (,�@ 0 ( ,1 L-uck ui O Cell Phone: (S7 ) 6o -/9 7e Land Line: ( ) C, Email: /LUr+h.erntn prises 5flLi 1 . am Addition/Alteration Application Revised February 2019 lh PROJECT INFORMATION: TYPE: Commercial V 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: Total square feet: \b ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ %-D0(3 2. If Commercial project, what is the proposed use: 3. Source of Heat (circle one): Gas Oil Propane Solar Other Fireplaces need a separate uel Burning Appliances & Chimney Application 4. Are there any structures not shown on the plot plan? YES CNC:)4) Explain: 5. Are there any easements on the property? YES NO 6. SITE INFORMATION: (i' 5- Acres a. What is the dimensions or acreage of the,parcel? 6 c res b. Is this a corner lot? YES SNO j c. Will the grade be changed as a resu construction? YES NO d. What is the water source? PUBLIC' PRIV E WELL e. Is the parcel on SEWER or a PRIVATE SEPTIC system? J iV e__ Addition/Alteration Application Revised February 2019 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: CIS 0 (3P SIGNATURE —r DATE: Addition/Alteration Application Revised February 2019