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Office Use Only ADDITION/ALTERATION PERMIT|Permit #:2c —0040-2920 APPLICATION Permit Fee:$_ASe-Ba259.09 Town of Queensbury 742 Bay Road,Queensbury,NY 12804 Invoice #:__2A20 P:518-761-8256 www.queensbury.net Project Location:B Glonmar De Tax Map ID #:Subdivision Name: CONTACT INFORMATION:{fy | ©Applicant: } | Name(s):a?)Sock 6 ch,etMailingAddress,C/S/Z:__47 Sap OQdry ES Cell Phone:(S)e_)_222-976 Land Line:’_(_—) Email:__gbucke 7b gmasl.com »Primary Owner(s): Name(s):AZ Lh rye €Aody Snide Mailing Address,C/S/Z:_2?Glenmarc De Cell Phone:_(S)5_)94H b tEE land Line:_(__—) Email:_Yatheyna«Aitohen @on.Va Com Ci Check if all work will be performed by property owner only ©Contractor(s):Workers’Comp documentation must be submitted with this application Contact Name(s):_deol (ud Contractor Trade:_Geaucol Corte Mailing Address,C/S/Z:_Vb Cay 2,/ Cell Phone:_(Si<_)_222-97b¢*Land Line:_{) Email:_phucke 9765@ oyros\com*+List all additional contractors on the back of this form ©Architect(s)/Engineer(s): Business Name:UJ Mian PL Jill ‘E Contact Name(s):{Yon Wincor Mailing Address,C/s/z:_S'09 Glen Sk Cas EAs ANY Cell Phone:_(S7€)795-7466 F Land Line:_() Email:Aon @ willvom sandal amcde pau,Com Contact Person for Building &Code Compliance:v Me ‘ao Cell Phone:_(Q&_)_222-975 Land Line:_() Email:_9 back G765@ aye S\.orm. AdéiionAlteration Application Revised tanuary 2020, PROJECT INFORMATION: TYPE:Commercial %K Residential WORK CLASS: Single-Family __Two-Family ___Multi-Family (#of units ) __Townhouse ___Business Office __Retail __Industrial/Warehouse Garage (#of cars )Other (describe ) ADDITION SQUARE FOOTAGE:ALTERATION SQUARE FOOTAGE: Ast floor:ist floor:__3S2"floor:6 2"4 floor:QO 3 floor:oO 3°floor: Basement (habitable space):_O Basement (habitable space):_© 2Totalsquarefeet:__\\7.Total square feet:___9S__ ADDITIONAL PROJECT INFORMATION: 1.Estimated Cost of Construction:$.S000 2.If Commercial project,what is the proposed use: 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 (NO)Explain: 5.Are there any easements on the property?YES 6.SITE INFORMATION: a.What is the dimensions or acreage of the parcel?3s b.Isthisacornerlot?YES 0)_ c.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 PRIVATE SEPTIC system? Adaiion/Ateration Application Revised lanuary 2020, DECLARATION: 1.Lacknowledge 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. 5.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 acertificate of occupancy. Ihave read and agree to the above: printname:__tedrick (Suche sionarure:Panne L.AL.DATE 24)/202 -Additon/Alteration Apolieation Revised January 2020,