application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: -RSA'-
APPLICATION t,' ,o°
Permit Fee:$
TOVfil of aensbwy ._
742 Bay Road,Queensbury,NY 12804 Invoice#: (9.}£t
P:518-761-8256 www.queensbury.net
Project Location: r
Tax Map ID#: 2/® 6 0 6 /-]/ Subdivision Name: A/jA
CONTACT INFORMATION:
• Applicant:
Name(s): "Vial 6A,1s
Mailing Address, C/S/Z: -3h,0 2F8 G`e✓-IYd e fiy /26)2 0
Cell Phone: (.SZ8) ?3 y - 33 J-7 Land Line: �( )
Email: A, c ' cc 9f /J)
• Primary Owner(s):
Name(s): (",t.- U4 Jt ,11e
Mailing Address, C/S/Z: -O 3410 3L1/ 69 �r Fl ,?36%L/
Cell Phone: { 378 ) .?3 - Land Line: ( )
Email: c,c c 9S /' A,.6-;/t
• Contractor(s):
Business Name:
Contact Name(s): ._
Mailing Address, C/S/Z: I li\ E ( t 0 it I I' i
Celt Phone: ( ) Lan e: _( ) I I I I
Email: � I AUG202018 il1.1) l
uur ' —
• Architects)/Engineer(s): TOWN OF QUEENSBURY
BUILDING&CODES
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: { )
Email:
Contact Person for Building& Code Compliance:
Cell Phone: ( ) Land Line: ( )
Email:
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
PROJE@' -JNFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
_Single-Family Two-Family Multi-Family(#of units )
_Townhouse _Business Office _Retail
_Industrial/Warehouse !` Garage (#of cars 3 ) _Other(describe )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement(habitable space): Basement(habitable space):
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 2.Ori
2. If Commercial project,what is the proposed use:
3. Source of Heat (circle one): Gas Oil Propane Solar Other A1oN�'
Fireplaces need a separate Fuel Burning Appliances&Chimney Application
4. Are there any structures not shown on the plot plan? YES CI Explain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the s: cel? 6 , 33 ette
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result o e constru - YES NO
d. What is the water source? PUBLIC PRIVATE WELL ,,��
e. is the parcel on SEWER or a PRIVATE SEPTIC system? Nb
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018
DECLL-RATION:
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:
SIGNATURE: \Q,
\pEC�� OATE:
•
•
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised March 2018