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application
Office Use Only ADDITION/ALTERATION PERMIT|Permit #:2<,-005%-2020 APPLICATION Permit Fee:$_2OO ~ Town of Qucenbary 742 Bay Road,Queensbury,NY 12804 Invoice #:_2 240, P:518-761-8256 www.queensbury.net Project Location:NTS) Tax Map ID #:Pia.\4-\-26 __ Subdivision Name: CONTACT INFORMATION: *Applicant: Name(s):mi lnc. Mailing Address,C/S/Z:a 12627 Cell Phone:($75 )49/-6¢%o Land Line:_(¢7&)#%5-oul Email: +PrimaryOwner(s): Name(s):_CANE tre Acccadon Mailing Address,C/S/Z: Cell Phone:_(478)Hf tt land Line:_() Email:CAM ITE @ iT Perar.Biz O Check if all work will be performed by property owner only *Contractor(s):Workers’Comp documentation must be submitted with this application Contact Name(s):Dopol icant Contractor Trade:a Mailing Address,C/S/Z: Cell Phone:_()land Line:_( Email: **List all additional contractors on the back of this form ©Architect(s)/Engineer(s): Business Name: Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance:fen en Leryn} Cell Phone:_()Land Li ) Email: Addiion/Ateration Application Revised January 2020, PROJECT INFORMATION: V_ResidentialTYPE:Commercial WORK CLASS: Single-Family __Two-Family __Multi-Family (#of units __Townhouse ___Business Office __Retail __Industrial/Warehouse Garage (#f of cars )Other (describe.) ADDITION SQUARE FOOTAGE: Basement (habitable space): Total square feet: ADDITIONAL PROJECT INFORMATION: ALTERATION SQUARE FOOTAGE} Basement (habitable space): Total square feet: 1,Estimated Cost of Construction:$,22S \9.,56 CD.oO 2.If Commercial project,what is the proposed use: Propane Solar Other3.Source of Heat (circle ong GoiFireplacesneedaseparateFuelBurning Appliances &Chimney Application 4,Are there any structures not shown on the plot plan?YES 5.Are there any easements on the property? 6.SITE INFORMATION: NO Explain: YES No ‘Addition/Alteration Application a.What is the dimensions or acreage of the parcel? b.Is this a corner lot?YES NO ¢.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? Revised January 2020, DECLARATION: *<.-0024-2020 1.|acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within a 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.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.|acknowledge that prior to occupying the facilities proposed |,or my agents,will obtain a certificate of occupancy. Jalso understand that I/we are required to provide an as-built survey byalicensedlandsurveyorofall newly constructed facilities prior to issuance of a certificate of occupancy, Ihave read and agree to the above: PRINT NAME:os SIGNATURE:__2,a DATE:_#[2/,po20 ‘Addition/Alteration Application Revised January 2020