RC-0518-2020 Aug 12 2011:06a p.1
Office Use Only
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ADDITION/ALTERATION PERMIT Permit#: �� ZQZQ
,-,•444 :'*L',� , APPLICATION Permit Fee:$ 2.
Town of Qyccnslun• �►J�^
742 Bay Road,Queensbury,NY 12804 Invoice#: rei c)
P:518-761-8256 v vaw.queensibwy.net
Project Location: Wt\o/,S JIqV\ -
Tax Map 1D #: 301 It? - d - ) 6 Subdivision Name: NIECE'
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CONTACT INFORMATION: AUG 12 2020
e Applicant: j
Name(s): Ic' .u`' 0 BUILDI F OW ON F QUEEI�SBURY
NG&CpDES
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Mailing Address, C/S/Z: Sot f 6 ci_v�.St. is oa� >! ,i A '.
Cell Phone: (;'"('S ) 3a'-)- 11O , Land Line: IA-lc'''. ) 7?3 -Qa(>
Email: f i re.Cc3.-r 3 o SciC3 ( . Cio @ - Corn,
Primary Owner(s):
Name(ss): \c cL 1_ ct�i\-C autJ li.,5�� f okioce-
e.
Mailing Address, C/S/Z: ci, `71-, wi.„.s i. n...e Q t .Q,zitS 6.cx4/-77 A- V. 1 a Wil
Cell Phone: ( St ) 30i- f j 3 � Land Line: ( )
Email: ilwceti13 act tcc, t . coo",
❑ Check if all work will be performed by homeowner only
Contractor(s): W rkers'/)Comp documentation must be submitted with this application
Contact Name(s): J� L
-e o cQ 0
Contractor Trade: jeover.i I C�a,-rc cck-0"
Mailing Address, C/S/Z: ,5O1 r0,4s-eVoorf ell ,4—+ t--at, A/K./282r
Cell Phone: i ) 3 c=�- 1(6+- Land Line: ( 5! S- ) 713 -ce 6 2
Email: j retCc.v. 3/0 Sca.3 C,.ao 1 . C.,ate,
**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: I )
Email:
Contact Person for Building &Code Compliance: (J0 Le L0‘ct e
Cell Phone: „pi-tic ) 3 - ( ( 0 St. Land Line: (5 dq ) let 3 - q) 6 I
Email: p i r-eco v-2 k LScv_a:) 0..01 • Co 4,-
Addition/Alteration Application Revised February 2019
Aug 12 2011:08a p.7
PROJECT INFORMATION:
TYPE: Commercial X Residential
WORK CLASS:
Single-Family Two-Family Multi-Family(#of units )
Townhouse Business Office Retail
Industrial/Warehouse Garage (#of cars ) , Other (describe 14:n- 61/4j )
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: $ 1/, 70o .o,
2. If Commercial project, what is the proposed use:
3. Source of Heat(circle one): Gas Oil rop na a 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?
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? UBLIC PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? awc1/44-,e,
Addition/Alteration Application Revised February 2019
Aug 12 2011:08a p.6
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: j o5ckj
SIGNATU :—'`� DATE: ?'- '/ 070
Addition/Alteration Application Revised February 2019
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