application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: 60 2.- 2,avb
•
-- APPLICATION
Permit Fee:$ 5 Q
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
Invoice#: " .71
P:518-761-8256 www.queensbury.net
Project Location: 106 Luzerne Road, Queensbury
Tax Map ID #: 523400-309-9-2-7-0-0 Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): Anne Marie Zsamba/Crown Castle as agent for Dish Wireless
Mailing Address, C/S/Z: 3 Corporate Park Drive, Suite 101, Clifton Park, NY 12065
Cell Phone: ( ) Land Line: ( 201 ) 236-9224
Email: annemarie.zsambaPcrowncastle.com
• Primary Owner(s):
Name(s): 106 Luzerne Road LLC
Mailing Address, C/S/Z: 443 West Mountain Road, Queensbury, NY 12804
Cell Phone: ( ) Land Line: ( 201 ) 236-9224
Email:
• Contractor(s):
Business Name: Crown Castle
Contact Name(s): Tammy Nosek, CM
Mailing Address, C/S/Z: 3 Corporate Park Drive, Suite 101. Clifton Park, NY 12065
Cell Phone: ( 518 ) 860-7063 Land Line: (
Email:
• Architect(s)/Engineer(s):
Business Name: PM&A - P. Marshall & Associates
Contact Name(s): Mendy Benson
Mailing Address, C/S/Z:
Cell Phone: ( 404 ) 316-1682 Land Line: (
Email: mbensonPpmass.com
Contact Person for Building & Code Compliance: Anne Marie Zsamba
Cell Phone: f 518 ) 350-3639 Land Line: ( 201 ) 236-9224
Email: annemarie.zsambaPcrowncastle.com
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
PROJECT INFORMATION:
TYPE: X Commercial Residential
WORK CLASS:
Single-Family Two-Family Multi-Family (#of units
Townhouse Business Office Retail
Modification to telecom
Industrial/Warehouse Garage (#of cars tower.
g ) X Other (describe )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: NO CHANGE TO TOWER HEIGHT 1st floor:
2nd floor:_ AND NO COMPOUND 2nd floor:
3rd floor: EXPANSION INVOLVED. 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 30,000
2. If Commercial project, what is the proposed use: Site to remain a telecommunications tower.
3. Source of Heat (circle one): Gas Oil Propane Solar Other N/A
Fireplaces need a separate Fuel Burning Appliances & Chimney Application
4. Are there any structures not shown on the plot plan? YES XNO Explain:
5. Are there any easements on the property? YES XNO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? N/A
b. Is this a corner lot? YES NO N/A
c. Will the grade be changed as a result of the construction? YES XNO
d. What is the water source? PUBLIC PRIVATE WELL N/A
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? N/A
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
A �
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: Anne Marie Zsamba/Crown Castle as agent for Dish Wireless
SIGNATURE: DATE: IcTI�I LY
I I
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018