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Office Use Only ADDITION/ALTERATION PERMIT|Permit RC-0l10 ~Jo20 APPR|Town of 742 Bay Road,Queensbury,NY 12804 518-761-8256 www.queensbury.net ||| Project Location:8 ROCKWURSL)eowsO~ TaxMapio#:227.1$-2-40 subdivision Name:_H/ CONTACT INFORMATION: ©Applicant: Name(s):Tony Oi BELLA <Mailing Address,C/s/2:_72 Lox 257 Chaeele[e ,7/Y 12822 Cell Phone:_($18 )_B92 0028 landline:(615 )Sd 4449 Email:AF aa msn com ¢Primary Owner(s): Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_(). Email:, BA Check if all work will be performed by homeowner only ®Contractor(s):Workers’Comp documentation must be submitted with this application Contact Name(s): Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_(j Land Line:_() Email:, **List all additional contractors on the back of this form ©Architect(s) BusinessName: Contact Name(s):_CUIETIG D,DYBAS Mailing Address,siz WI»& Cell Phone:land Line:(918)((o8 554 emailADVBES€BNO.Cort Contact Person for Building &Code Compliance:.( Cell Phone:_().Land Line:_() Email: Addition/Areration Appiction Revised February 2018 PROJECT INFORMATIO! TYPE:Commercial X__Residential WORK CLASS: _X Single-Family __Two-Family __Multi-Family (#of units ) __Townhouse ___Business Office __Retail ___Industrial/Warehouse _X Garage (#of cars_2 _)__Other (describe. ADDITION SQUARE FOOTAGE:ALTERATION SQUARE FOOTAGE: Ast floor:__$70“2Fleer: :freerBasement(habitable space):Basement (habitable space):on Total square feet:Total square feet:2345 ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$_"200,G00.~ 2.If Commercial project,what is the proposed use: 3.Source of Heat (circle one):Gas Oil 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: 5.Are there any easements on the property?YES 6.SITE INFORMATION:yyWhatisthedimensionsoracreageoftheparcel?O&x\I5/0.244a b.Isthisacornerlot?YES ¢.Will the grade be changed as a result of the construction?WS we,@® d.What is the water source?-PUBLIE PRIVATE WELL e.Is the parcel on SEWER or a PRIVATE SEPTIC system?SeatSeerio ‘Addition/Ateration Application Revised February 2019 DECLARATION: 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.Ifthework 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 Jedge-that-prior te“occupaney FeastwhWile Be Aseo 0 PERT ceUPMCTPNutsColsfeuctias. 5.also understand that lAve 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. have read and agree to the above: PRINT NAME:Tow D Belk SIGNATURE:Lax E26.DATE:HL [ZZ ‘Addition/Alteration Application Revised February 2019,