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Office Use Only PERIATT re]CC outs-2og~~"Permit ek: $@00.00. SEP 11 28.|un Invoi tt:2 6° ADDITION/ALTEI APPLICATII ‘Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Project Location:FO __UPP’ Tax Map ID #:OZ “|-S@_J _.Subdivision Name:VA CONTACT INFORMATION: TOWN OF QUEENSBURY UILDING &CODES ©Applicant:ass =Name(s):_LOwoc eae Te.$,LLC.Conn Ce.) Mailing Address,C/s/2:A l\maoe bP lobe Stree NY [2698 Cell Phone:(GL©)#76 -1 SHS land Line:(14)Email:Vain Caer A b6G Gwen.Cow +Primary Owner(s): Name(s):__Goi Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: 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):_\ppe Gare/BUY VOn~Fronetne Contractor Trade:2 Mailing Address,C/s/Z:SAW Cell Phone:_(Sawif_Land Line:_() Email:__pry**List all additional contractors on the back of this form e Architect(s)/Engineer(s): Business Name:EXBLAn)“He (Bcmosie Hau Apettenen ie) Contact Name(s):__1344 Bay Ave Mailing Address,C/s/z:QUES pits NY |260 . CellPhone:(_)landline:_(_)Email: Contact Person for Building &Code Co!copple coothats Ge Seurcn Bnezerr Cell Phone:(SI®_)FAG-124 (St&)Qt =S2H (Baten Email:JOnw Gaoe-19660,CRDA ‘Addition/Alteration Application Revised February 2019 PROJECT IN FORMATION E =TYPE:30 Commercial Residential WORK CLASS: __Single-Family __Two-Family __Multi-Family (#of units ) ___Townhouse __Business Office Sc retail __Industrial/Warehouse Garage (of cars )Other (describe ) ADDITION SQUARE FOOTAGE:ALTERATION SQUARE FOOTAGE: Ast floor;LOC24flootBearEOS31floor,gaaraneaBasement(habitable space):Basement (habitable space): Total square feet:Total square feet:2707 ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$1S,G2 Leta [LE tae Suge Ss 3.Source of Heat (circle one):Gad Oil Propane Solar Other Fireplaces need a separate Fuel Burning Appliances &Chimney Application 2.If Commercial project,what is the proposed use: 4,Are there any structures not shown on the plot plan?YES©NO explai 5.Are there any easements on the property?yes CNO> 6.SITE INFORMATION: a.What is the dimensions or acreage of the parcel?ots b.Is this a corner lot?No c.Will the grade be changed as a result of the construction?YES We d.What is the water source?PUBLIC PRIVATE WELL e.Is the parcel onSEWER or a PRIVATE SEPTIC system? Adétion/Aterstion Application Revised February 2019 DECEARATION: 1.|acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within 2 12 month period. 2.Ifthe work 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. 5.1also understand that we are required to provide an as-built survey by alicensed land surveyor ofall newly constructed facilities prior to issuance of a certificate of occupancy. Ihave read and agree to the above: PRINT NAME:EHH SIGNATURE /—DATE:aff # Additon/slteration Application Revised February 2019