application Office Use Only
ADDITION/ALTERATION PERMIT Permit#:
APPLICATION Permit Fee:$ l`�'1 •`�a
Town ofQ u"nsbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.oueens11bury.net /�
Project Location: -, I/ Nfgh � #14e Yri pr 0. emsha-� �y
Tax Map ID#: 1 b, - 3 Subdivision Name:
CONTACT INFORMATION: 1i IE (ro E 0 W [E
• Applicant: JUL 0 5 2017 D
II
Name(s): -rJ 04n r, 11 �I
Mailing Address, C/S/Z: a h �n , Dry'j
Cell Phone: L)�7 ) - �' Land Line:
Email- --x-J oo„c C.qdwfimma
• Primary Owner(s):
Name(s): E�' izuheP - I - do ,
Mailing Address, C/S/Z: Q ) I�,( � l 07 of Ltiv--e-
Cell Phone:_�} Land Line:
Email:
• Contractor(s): _
Business Name:XOter ✓i -&z S-c S
ContactName(s): fldaW, lork
Mailing Address, C/S/Z:_(o Ser, 6v U5 Dri f-c , L,� Ce0,a. , I'1 y [� S y 4�-
Cell Phone: S( 1 q )-93)- V,/ 77 Land Line: �)
Email: Gyorkyie ho�rn4iI [ o pv%--
• Architects)/Eneineer(s):
Business Name: r_) vJ �h fEJ�iL°reraC
ContactName(s): 2wrG. l 6olcu.AON
Mailing Address, C/S/Z:
Cell Phone: ( Sl St' ) - 7�! - C�f'G Land Line: T l t<
Email:---b -C, lel . = }�' i'+ t C • ��
Contact Person for Building & Code Compliance:_
Cell Phone ) � Cil Land Line: > ) ;7 3
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial 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:
1st floor: i0 floor:
211 floor: 211 floor:
3'floor: 31 floor:
4"floor: 41h floor:
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 1�z) ao V
2. If Commercial project, what is the proposed use: I
3. Source of Heat (circle one): Gas Oil Propane Solar Other
Fireplaces need a separate FbeHfurning 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 NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of thrte
cel? C)v b 3
b. Is this a corner lot? YES
c. Will the grade be changed as a re ctonstruction? YES NO
d. What is the water source? PUBLIC PRIVATE WELL
e. Is the parcel on SEWER or a,"PRIM 1I ystem?
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017
DECLARATION:
1. 1 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. 1 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. 1 also understand that I/we are required toprovide an as-built survey by a licensed land surveyor of all
newly constructed facilities priorto issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: Jox7st
SIGNATURE:� � - ' , _ -. .._ - DATE: ,
Town of Queensbury Building&Code Enforcement Addition/AReration Application Revised February 2017