application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: -^C5( "2-O2.O
APPLICATION Permit Fee: $ haf6QtadistiZr /2S.
Town of Qeensbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.queensbury.net
Project Location:'15u Epp-erCy N7, v-sb N'-i I-2-(5�`f
Tax Map ID#: t23$5'llq Subdivision Name: ot2-eottl vibes 518 Wkritivi
3O2 ,c1-51 . 2_.
CONTACT INFORMATION:
® Applicant:
Name(s): 4jQ&CiCee Stvcia
Mailing Address, C/S/Z: lytt,<A„ 1. 6-e-°15,Ncsi 17-6g6 '
Cell Phone: t 3-�
_(5 � ) 47, � Land Line: _( ) ,/ _�� �®
Email: cotzlutbes 5tghut -hi,,,@9vuta.,1, Cry : °j' :�. `�� /
® Primary Owner(s):
Names Co. Z/o fVfichae l Paturnb.� `'
Mailing Address, C/S/Z: gooAytirews&•Svi e Soo ,Ny tyto
Cell Phone: ( 555 ) 5,4b•.f (o(P Land Line: _( )
Email: vh patum bo C'Rauvn inj co vH
❑ Check if all work will be performed by homeowner only
® Contractor(s):
Contact Name(s): C Cprkew Coksk-rucX ov1
Contractor Trade: G6Ncepa_ CbarQAL?o'P-
Mailing Address, C/S/Z: 5tro'►rw% Kosa trAu.s,p4 t 3a
Cell Phone: _(5t9 ) Dti-3313 Land Line: _( )
Email: easel(ar (ewk'iW1a,i\.Covv.
**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: C. &-yiCv•-)
Cell Phone: _( 5t8 ) 112-3Y13 Land Line: _(
Email: Casey co re w C g vaa.1 Cow
Addition/Alteration Application Revised February 2019
.
PROJECT INFORMATION:
TYPE: j' Commercial ❑ Residential
—WORK-CLASS:—
Single-Family ['Two-Family ❑Multi-Family (#of units
['Townhouse El Business Office IgRetail ❑ Industrial/Warehouse
❑ Garage (#of cars ) ❑ Other(describe
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: • 'g 1st floor: 'I-o51.-
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: 670-
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ (02_00-
2. If Commercial project, what is the proposed use: W(,\ul,ISynod'hhe IhOutn
3. Source of heat: ®Gas❑Oil❑Propane❑Solar ['Other Fireplaces need a separate Fuel
Burning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? EYES 12NO Explain:
5. Are there any easements on the property? EYES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel?
._._Is-t is-a-corner lot? DYES _ ._ ®NO
c. Will the grade be changed as a result of the construction? EYES ENO
d. What is the water source? (PUBLIC ['PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? SEwt(-(-row N)
Addition/Alteration Application Revised February 2019
DECLARATION:
-- ----17—l-aeknowledge-that-no-constr-uction-shall be commenced prior to issuance-of a-valid-per-mitand-wilt-=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
cQ� r_ttcLf��ilities_prior_to.issuance of a certificate of_occupancy, _
I have read and agree to the above:
PRINT NAME: ,odaon
SIGNATURE: DATE: 'jgf20
Addition/A t�eration Application Revised February 2019