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application Office Use Only ADDITION/ALTERATION PERMIT Permit#: aC. "' 06( — Z-D APPLICATION Town ofQue nairy Permit Fee:$ ZOO — 742 Bay Road,Queensbury,NY 12804 P:518 78]-$256 www.queensbury.net Invoice#: Project Location:_57 Minnesota Ave Tax Map ID#: Subdivision Name: ,a � � ;n CONTACT INFORMATION: JUN 19 2020 • Applicant: TOWN OF O.UEENSBURY Name(s): Paul l Harrington BUlLDI J^ rU CODES Mailing Address, C/S/Z: Queensbury NY 12804 Cell Phone:_( .) Land Line: _( 518 ) 761-6824 Email: • Primary Owner(s): Name(s): Paul E Harrington Mailing Address, C/S/Z:_Queensbury, NY 12804 Cell Phone: ( ) _ Land Line: _(,518 ) 761-6824 Email: X Check if all work will be performed by homeowner only • Contractor(s): 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: Cell Phone:_( ) _ Land Line: _(� ^) Email: Addition/Alteration Application Revised February 2019 is 9S 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: 1st floor: 1st floor:_186.11 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: $ 15,000 2. If Commercial project,what is the proposed use: 3. Source of heat: ❑Gas❑OilLJPropane❑Solar ❑Other • Fireplaces need a separate Fuel Burning Appliances&Chimney Application 4. Are there any structures not shown on the plot plan? DYES XNO Explain: 5. Are there any easements on the property? OYES NO 6. SITE INFORMATION: a. What is the dimensions or acreage of the parcel? _100'x100'_ b. Is this a corner lot? OYES ©NO c. Will the grade be changed as a result of the construction? OYES ®NO d. What is the water source? ®PUBLIC ❑PRIVATE WELL e. Is the parcel on SEWER or a PRIVATE SEPTIC system? Private Septic Addition/Alteration Applicalion Revised February 2019 \ I DECLARATION: 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: Pa,JI-E�Harrington / SIGNATURE./ DATE: 6`1d--`2° 24) Addition/Alteration Application Revised February 2019