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ADDITION/ALTERATION PERMIT Permit#: C C. - 0 L-E ( q Z-0
APPLICATION -•ed- i '�Tw�Z ' O
T of• „ . pE E - EN
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net MI MI
I
SUN • 2019
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Project Location:
TOWN OF QUEENSBURY I
c� BUILDING & CODES
Tax Map ID #: 30� ; 2 U-- (
I - • �� 31iB.`ivisi n varere:
CONTACT INFORMATION:
• Applicant:
Name(s): t1M q t l2 " ' 1)1,4' 2 , LLG .
Mailing Address, C/S/Z: - •.S iTo 17 4:42-O/'cP S•1" • 5Vt' 320 GLA.fS p-L,I,.S Ny
Cell Phone: ( .5(0 ) 3'( - (2- Land Line: ( ) ('10.0
Email: 1-1 W& �Ja 1 rDvr(\ C- ' Lo►'h
• Primary Owner(s):
Name(s): • rtie
Mailing Address, C/S/Z:
Cell Phone: ( ) 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): O/
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: $ 41%(2-C p?st6NI G120 /7 (A
Contact Name(s): > 1%o+y1 0
Mailing Address, C/S/Z: 1304, G>l r V(c ti $ z4 )► ILb
Cell Phone: ( ) 5.4roA Land Line: ( 5W ) 60a- 0 362
Email: �1nO rat re.h o{e S l rw ire v p 1 „A.,, ► I C�o.+n
Contact Person for Building & Code Compliance: I ( M F3
Cell Phone: ( 51$ ) '36' ( - r?-c,q• Land Line: ( )
Email: '014Mi
i Addition/Alteration Application Revised February 2019
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PROJECT INFORMATION:
TYPE: k Commercial Residential
WORK CLASS:
Single-Family Two-Family Multi-Family (#of units
Townhouse Business Office Retail
1 Industrial/Warehouse Garage (#of cars ) Other (describe 1 �
42V34GV1 Fag—.r Mr
ADDITION SQUARE FOOTAGE: IormtG ALTERATION SQUARE FOOTAGE:
1st floor: A4W4 c 14,,togildist floor: 4 11 7 1 O_ 5miew
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: '
M9-rr 1T
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ADDITIONAL PROJECT INFORMATION: /Iv"
1.! Estimated Cost of Construction: $
2.! If Commercial project, what is the proposed use: -yn,a- h..4
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 xplain:
5.! Are there any easements on the property? YES
6.! SITE INFORMATION: l
a.! What is the dimensions or acreage of the p rcel? I '1
b.! Is this a corner lot? YES
c.! Will the grade be changed as a result he construction? YES
d.! What is the water so ? P C PRIVATE WELL
e.! Is the parcel on SF r a PRIVATE SEPTIC system?
MVP
Addition/Alteration Application Revised February 2019
I
E ECLARATION:
2/! I acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period.
3/! If the work is not completed by the 1 year expiration date the permit may be renewed, subject to
fees and department approval.
4/! 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.
5/! I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
6/! 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 M SM'2Sera..._
SIGNATURE: DATE: 447A�
Addition/Alteration Application Revised February 2019