application 4
Office Use Only
# "M' ADDITION/ALTERATION PERMIT Permit#: ` ® ° `Z-®lei
APPLICATION Permit Fee: $ ICJ "
Town of Queens bury
742 Bay Road,Queensbury,NY 12804
Invoice#: 1 5'=\
P:518-761-8256 www.Queensbury.net
Project Location: ,5--- 7 ' , DE_ o vv
Tax Map ID #: 3o 1. -I- 5-7 Subdivision Name: D ° cIlEuvE4
MAY 2 2 2019 Li
CONTACT INFORMATION:
TOWN OF QUEENSEURY
• A licant: BUILDING&COBRS
Name(s): g � e
_ I
Mailing Address, C/S/Z: ti-mit(
Cell Phone: (5i ' ) � —t Land Line: ( s�E ) 5c6
Email: /01-JS tom "3 f e ems
• Primary Owner(s):
Name(s): 0--C4-04A, ri c Lein
Mailing Address, C/S/Z: LAtAi�� -e, „-� ._ 126y'
Cell Phone: (-Sq ) Land Line: ( 6`g r ) 2 cJ -ss ate.
Email: /Op)/ ,0 m -wf
❑ 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 ( p, c,j
Contractor Trade:
Mailing Address, C/S/Z: "��f upi
Cell Phone: ( ) 7`7 s i 9 Land Line: (
Email: 4`o��7. & (Oh
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building & Code Co> liance: - w '
Cell Phone: ) Land Line: (
Email: /Oriq 4(3 ( yfig_A eTz49,
Addition/Alteration Application Revised February 2019
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• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade: ' '- P—. ,.
Mailing Address, C/S/Z: 4'-7L/ L -7(_ 514e7Lin 19-A.) 4- ,
Cell Phone: ( > ).� -7C Land Line: ( )
Email: D J - 7 Mit ceriev
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial de 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" floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: 3 t. Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 3 1
2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one): Gas Oil Propane Solar Other i J
Fireplaces need a separate Fuel Burning Appliances & Chimney Application
4. Are there any structures not shown on the plot plan? YES Explain:
5. Are there any easements on the property? YES
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 0
d. What is the water source? PUBLIC PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system?
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: „ ,�.� 1 e:A 5.
SIGNATURE: DATE: '— /e
Addition/Alteration Application Revised February 2019