application Office Use Only
ADDITION/ALTERATION PERMIT Permit.#: CC: - 95` -\- 2020.
APPLICATION Permit Fee:$ 10.
Town of Qecnsbury
742 BayRoad,Queensbury,NY 12804 )
Invoice#: � 5 ..
P:518-761-8256. www.queensbury.net
Project Location: r a g C9tkec A .R_ a,, '. ,� •
n C E
•Tax Map ID.#: ., 03 5 ICJ Subdivisi Named
SEP 22 •7121 •
CONTACT INFORMATION R
TOWN OF OUEENSBU Y
BUILDING&CODES
Applicant:. -
Name(s)+ 1\ �:5'�lru � ' O
Mailing Address, C/S/Z::: (. C12o c �f� : �� D.0-o1:: . -/-/itd 06 Fa i5 Al y : % /
Cell Phone: (:. • ..) Land Line: (5!cS ). .79?_62 3.q? : :
Email: 2./hdy ::: c i/.;.I/ yi(..)..ol5trzcdtc,1&) (Lb
• Primary Owner(s):
y ,) LLB
:Mailing Address :C S/Z '7a .. q c �. :.. o: �n� 1�2r°6� i��r°
Cell Phone: . (, La
nd .
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•
Email: . .
O Check:if all work:will be performed by homeowner only .
• Contractor(sj: Workers':Comp documentatiort must be submitted with this application
Contact Name(s) t-i 1 1 I+O .. .
:Contractor Trade:
:N Mailing.Address, C/S/Z: :,5 f (��CO/ �'ac�ek it r c d so� .://5 /023 f
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:Cell Phone: ( ) . Land Line: (5/ F. .) .qq oy
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Email:C ihcfya ,. .:h: ./l-Forap J5-/flA ion co :
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: -e. .12
Contact Names ;. . .
Mailing Address C S/Z: 4 0 6 5:4/b vi S} /2 O )
Cell Phone: ( ) : . Land Line: : (:5/.? ) _7 : :I
Ema :.. . . . . .. •
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: Contact Person for Building &Code:Compliance::. . / Orn /7.7 re6-n.' ! 12
Cell Phone: ( `5) ) Ro2 F70cf Land Line:. . ( .5/ )
kilLfv�:C:U 15fii'ti:cfi o/.i Co.- Co rn- . •
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: n Commercial Residential
WORK CLASS:
—Single-Family —Two-Family —Multi-Family (#of units )
Townhouse Business Office Retail
Industrial/Warehouse —Garage (#of cars ) )C Other (describe&C'I'V) C- L' )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: t 36,0o S 5-P 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: L3 (900 Total square feet:
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ )g 00 (9
2. If Commercial project, what is the proposed use: AU-Pi On Q.Q Seff f c e 'iyS
3. Source of Heat (circle one): 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? YES NO. Explain:
5. Are there any easements on the property? YES - NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the cel? 3; &,h l4 c hill 0 x gS4t/
b. Is this a corner lot? YES 10
c. Will the grade be changed as a result • he construction? YES ..05.3)
d. What is the water source? PUB PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTI system?
Addition/Alteration Application Revised February 2019
DECJARATION:
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: Cl racy 91k reciyfr
SIGNATURE: DATE: q--ov " 02 "ID
Addition/Alteration Application Revised February 2019