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Office Use Only 5 $2010 ADDITION/ALTERATION PERMIT.|Permit _Rc-olFOO[peesV Permit Fee:$_S00.O invoice #:2UY 3 Town of Queensbury 742 Bay Road,Queensbury,NY 12! P:S18-761-0256 yoww.queensbury Project Location: Tax Map ID CONTACT INFORMATION: ©Applicant: Name(s):(Scie Hoa.ouly Mailing Address,C/s/Z:_4%Richardson Sr Qotenouny NY lagoy Cell Phone:(S18 )G36 0037 Land Line:_() Email:BE B acae Ay @ Gora.Or +Primary Owner(s): Name(s):Go Veanerky Renate Mealy Mailing Address,C/S/Z:_ScAye_ag also Xe Cell Phone:_()Land Line:_() Email: 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): 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: Contact Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance:hv corte Cell Phone:_{)Land Line ) Email: ‘Addiion/Ateraton Application Revised January 2020, PROJECT INFORMATION: TYPE:Commercial X_Residential WORK CLASS: X single-Family __Two-Family __Multi-Family (#of units ) __Townhouse ___Business Office __Retail ___Industrial/Warehouse ___Garage (#of cars )__Other (describe ) ADDITION SQUARE FOOTAGE:ALTERATION SQUARE FOOTAGE: Basement (habitable space):Basement (habitable space| ADDITIONAL PROJECT INFORMATIO! 1. 1st floor: Total square feet:Total square feet: Estimated Cost of Construction:$.ty O00 If Commercial project,what is the proposed use:=Source of Heat (circle one):Gas Oil Prony?Solar Other Fireplaces need a separate Fuel Burning Appliances &Chimney Application Are there any structures not shown on the plot plan?YES (NO)Explain Are there any easements on the property?YES Go) SITE INFORMATION: What is the dimensions or acreage ofthe parcel?g Aa teaye Is this a corner lot? Will he grade be changedasa resul the construction?YES @o) What is the water source?PUBLIC PRIVATE WELL Is the parcel on SEWER or a PRIVATE SEPTIC system?sep c paoge ‘Adéiion/Alteration Application Revised January 2020 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,|acknowledge that prior to occupying the facilities proposed |,or my agents,will obtain a certificate of occupancy. 5.also understand that Ive 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:Brinn He SIGNATURE:DATE:a{oloo ‘Additon/Alteration aplication Revised January 2020