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Office Use Only ADDITION/ALTERATION PERMIT Permit#: CC — ©'J(Qr1-• - 2,0n1 APPLICATION Permit Fee:$ 2�' Z Town of Queensbury 742 Bay Road,Queensbury,NY 12804 Invoice#: P:518-761-8256 www.queensbury.net Project Location: 24 Quaker Ridge Blvd Queensbury,NY 12804 Tax Map ID#: Subdivision Name: ) ILs - s� _. ll111 DUN042019 CONTACT INFORMATION: �. 1.17 TOWN-OF QUEENSBURY • Applicant: &CODPS Name(S): Leticia Martinez Mailing Address, C/S/Z: 1705 S.Walton Blvd Suite 3, Bentonville,AR 72712 Cell Phone: ( )479-273-7780 x263 Land Line: ( Email:leticia.martinez@hfa-ae.com • Primary Owner(s): Name(s): Walmart Inc Mailing Address, C/S/Z: 2001 SE 10th StBentonville,AR 72712 Cell Phone: ( )479-273-4000 Land Line: ( Email: ❑ Check if all work will be performed by homeowner only • Contractor(s): Workers' Comp documentation must be submitted with this application Contact Name(s): Christopher Coffie w/G M Crisalli and Associates Contractor Trade: Mailing Address, C/S/Z: Cell Phone: ( )C 315.416.6381 Land Line: ( )315.454.0000 Email:Ccoffie@gmca.com **List all additional contractors on the back of this form • Architect(s)/Engineer(s): Business Name: Harrison French&Associates Contact Name(s): Leticia Martinez Mailing Address, C/S/Z: 1705 S.Walton Blvd Suite 3, Bentonville,AR 72712 Cell Phone: ( )479-273-7780x263 Land Line: ( Email:Leticia.martinez@hfa-ae.com Contact Person for Building & Code Compliance:Leticia Martinez at Harrison French&Associates Cell Phone: ( )479-273-7780x263 Land Line: ( Email:Leticia.martinez@hfa-ae.com Addition/Alteration Application Revised February 2019 • Contractor(s): Workers' Comp documentation must be submitted with this application Contact Name(s): Christopher Coffie w/G M Crisalli and Associates Contractor Trade: Mailing Address, C/S/Z: Cell Phone: ( )C 315.416.6381 Land Line: ( Email:Ccoffie@gmca.com • 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: f ) 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: I ) 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: X Commercial Residential WORK CLASS: Single-Family Two-Family Multi-Family (#of units Townhouse Business Office Retail Industrial/Warehouse Garage (#of cars ) Other(describe CANOPY 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: 1296SF Total square feet: ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ 119,000 2. If Commercial project, what is the proposed use: Existing : M 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 NO Explain: NO 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? 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: Leticia Martinez SIGNATURE: DATE: 6/3/2019 Addition/Alteration Application Revised February 2019