application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: CC-01025 -2420
APPLICATION Permit Fee: $ kel'FJ
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.queensburv.net
Project Location: 6 O fz u • ,. "' - -
D
Tax Map ID#: Ja 2,.7 - 9.(-1 Subdivision Name:
2020
CONTACT INFORMATION: TOWN OF QUEENSBU Y
BUILDING c woos
• Applicant:
Name(s): \<.4cJo_.S
Mailing Address, C/S/Z: ILO SL.J {- RA. Q eevisS ory JU`Q VZ?o `(
Cell Phone: (51 ? ) 7C1 • 9 33 g' La Ljne: (sib ) 33?-$`I91?.
St 40-let
Email: p1 KC AJOA5'
• Primary Owner(s):
Name(s): 141:akae,( & S'or0.•,n
Mailing Address, C/S/Z: Z O, E.( Z6 8 C(eve.r 1e N Y
Cell Phone: ( 51 3 ) 7 16-7 166 Land Line: (SI 3 ) C5, - 9 -1't`t
Email: Tll1\ 1Lul5 ° . vw et - Cryr''t
•
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z: Sc.) e.ei cto r7 yZ(ge)
Cell Phone: ( 518 ) L Line: ( 518 ) 3. 8- z`V t
Email: till K AJDAS-2- . Cav✓l
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact Person for Building & Code Compliance: 01 ;c he \ V-\c...k\c\C` -
Cell Phone: ( 5 I S ) 79 I.c?3 313 Land Ljne: (S1 0 ) 33$'- $9 9`7
Email: M <A;C PAS�G�TWC , Cov— `
Addition/Alteration Application Revised February 2019
•
PROJECT INFORMATION:
TYPE: ) Commercial Residential
WORK CLASS:
Single-Family Two-Family Multi-Family (#of units
Townhouse Business.Office Retail
•
Industrial/Warehouse Garage (#of cars ) )C Other (describe 5 1 f
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: $ 1000 p6
2. If Commercial project,what is the proposed use: 5 .10 (7
3. Source of Heat circle one): Oil Propane Solar Other
Fireplaces need a separate Fuel Burning Appliances&Chimney Application
4. Are there any structures not shown on the plot plan? YES Explain:
5. Are there any easements on the property? YES 4110
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? (. �6 k CAS
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? P PRIVATE WELL
e. Is the parcel ofileor a PRIVATE SEPTIC system? 5 Ew 1Z
Addition/Alteration Application Revised February 2019
DEGLAR'AT1ON:
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: / I I ch a.eI A . cs
SIGNATURE: DATE: ZZ
a
Addition/Alteration Application Revised February 2019