application Office Use Only
'. ADDITION/ALTERATION PERMIT Permit#: -C-0�-12-- 2°2-0
A APPLICATION Permit Fee:$ ' 200
Town ofQucensbury
742 Bay Road,Queensbury,NY 12804 Invoice#: 3)1-r+
P:518-761-8256 www.queensbury.net
Project Location: Z.O :-Iffn Li flW)I 1 jad. Q -c, r),SLUAj )22OL)
Tax Map ID#: v2 7 i , I5-- I-7 2- Subdivision Name:
CONTACT INFORMATION: •
• Applicant:
Name(s): rLS--h r .
Mailing Address, C/S/Z: 12O Jt fl ki ns U t 11 z ad. Covlr-c-il bL.,l l 2$O y
Cell Phone: (5-1% ) c321 -3219 Land Line: ( )
Email: 1__-LiC-L61 C? c 1cif I . C o in
• Primary Owner(s)7
Name(s): -4 A-n±hc^3Yn\,/ —I-CACk-�1r'
Mailing Address, C/S/Z: NZ-
Cell Phone: (S t g ) 22- Z.. Land Line: ( )
Email: 4 `,�s!-e `1�ze -�-e�-t c jiY2ao%.GOY1)
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): cxrj BL\Ic3Ycl
Contractor Trade: eC)115 �--I 1 on
Mailing Address, C/S/Z: ISI rry---.1 Ed _ ofj ZQOS-
Cell Phone: (51' ) 9 240 g4-4 1-1 Land Line: (
Email: g��1 1?• ofrY) r
**List all additional contractors on the back of this form ,� 1
• Architect(s)/Engineer(s): NOV i 3 2020 l
Business Name: TOWN T_V�lN OF OUFs"N,N iRV
Contact Name(s): BUILDING&CODES
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
Contact Person for Building& Code Compliance: ( rckov
Cell Phone: ( ) Land Line: ( )
Email:
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
i
TYPE: Commercial Residential
W K CLASS:
/Single-Family _Two-Family _Multi-Family (#of units )
Townhouse Business Office Retail
_Industrial/Warehouse ./ Garage (#of cars 2- ) _Other (describe )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement(habitable space): J i Y1c OC3
on kl
Total square feet: Total square feet: la Scj -E4-
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ J.►,�60 c e) a
2. If Commercial project, what is the proposed use: 1) (cx_
3. Source of Heat (circle one): Ga 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 N Explain:
5. Are there any easements on the property? YES CNO )
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? / '7 9 k /S O C.Ce2. r.`c vc)
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construc ' ? YES NO
d. What is the water source? PUBLIC RIVATE WELL '
e. Is the parcel on SEWER or a PRIVATE SEPTIC system: _ . f% C.
Addition/Alteration Application Revised February 2019
DECLARATION:
is
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 NAM E: Alris--fin
SIGNATURE: V - - DATE: l J1/Z}Zc3
Addition/Alteration Application' Revised February 2019