application , _
�`1 Office Use Only
llio
`` a `'.l ADDITION/ALTERATION PERMIT Permit#: CC -Oeo9 ' 2-026
r•.`*�-rat J#I
'i :. � art: APPLICATION Permit Fee:$ 1'✓
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#: 2,
P:518-761-8256 www.queensburv.net
Project Location: 1099 Ridge Road
Tax Map ID #: 290.5-1-48 Subdivision Name: NA
CONTACT INFORMATION:
• Applicant:
Name(s): Elizabeth Miller
Mailing Address, C/S/Z: 1071 Ridge Road , Queensbury NY 12804
Cell Phone: ( 518 ) 744-2273 Land Line: ( 518 ) 793-4300 Ext 301
Email: emiller@millermech.com
• Primary Owner(s):
Name(s): Same
Mailing Address, C/S/Z:
Cell Phone: ( ) „ _ Land Line: ( )
Email:
❑ Check if all work will be performed by homeowner only
® Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): Cifone Construction Co Inc
Contractor Trade: General Contractor
Mailing Address, C/S/Z: PO Box 684
Cell Phone: ( 518 ) 361-0626 Land Line: ( 518 ) 792-9242
Email: mcifone@cifone.com - .y=.
**List all additional contractors on the back of this form D G °'� fir.,•
• Architect(s)/Engineer(s): 1 JUL 0 2 2020
Business Name: NA ...� _ -.-_7-.
Contact Name(s): r, M(Z. i. ,,;€t S
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: Matt Cifone
Cell Phone: ( 518 ) 361-0626 Land Line: ( 518 ) 792-9242
Email: mcifone@cifone.com
1 Addition/Alteration Application Revised February 2019
.
PROJECT INFORMATION:
TYPE: 14, Commercial Residential
WORK CLASS:
_Single-Family Two-Family _Multi-Family (#of units
Townhouse Business Office Retail
Industrial/Warehouse Garage (#of cars ) _Other(describe vegetable stand
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor: 221
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: 221
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 3000
2. If Commercial project, what is the proposed use: same as it is vegetable stand
3. Source of Heat (circle one): Gas Oil Propane Solar Other NA
Fireplaces need a separate Fuel Burning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? YES Mpf Explain:
5. Are there any easements on the property? YES
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? 9.5 acres
b. Is this a corner lot? YES
c. Will the grade-be changed as a result of the cons uction? YES
d. What is the water source? PUBLIC VRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? NA
Addition/Alteration Application Revised February 2019
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: Matt Cifone
SIGNATURE: Digitally signed by Matthew J DATE:
Cifone
" ` ; DN:cn=Matthew J Cifone,
o=Cifone Const.Co.Inc.,ou,
email=mcifone@cifone.com,
J CS n
c=US
Date:2020.07.02 14:42:57-04'00'
Addition/Alteration Application Revised February 2019