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";'wap► ADDITION/ALTERATION PERMIT Permit#:e-C- 0 to 5z ' 20 2© APPLICATION Permit Fee: $ 742 Bay Road,Queensbury,NY 12804 b Invoice #: P: 518-761-8256 www.queensbury.net Project Location: _136 Cleverdale Rd. Tax Map ID #: _227.17-2-33 Subdivision Name: \ A CONTACT INFORMATION: • Applicant: Name(s): __Morgan Gazetos Mailing Address, C/S/Z: _57 Chapman St.. Ballston Spa, NY 12020 Cell Phone: _(_518_)_260-9878 Land Line: _( ) Email: _morganbuildsrunotmail.com . _,_i O • Primary Owner(s): c^ Name(s): James Broda i70 Mailing Address, C/S/Z: 122 Cleverdale Rd.. Queensbury, NY 12804 Z5P N Cell Phone: _(_518_)_683-0004 Land Line: _( ) ;tern n Email: �- A ! ' ❑ Check if all work will be performed by homeowner only 1 • Contractor(s): Contact Name(s): _Morgan Gazetos Contractor Trade: _Carpentry Mailing Address, C/S/Z: _57 Chapman St.. Ballston Spa, NY 12020 Cell Phone: _(_518_)_260-9878 Land Line: _( ) Email: morganbuilds/u,hotmail.com **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: 1 P'` \\--- Cell Phone: _( ) Land Line: _( Email: PROJECT INFORMATION: TYPE: ❑ Commercial 0 Residential WORK CLASS: 2 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: 1st floor: _131 sq. ft 2nd floor: 2nd floor: _N/A 3`d floor: 3`d floor: N/A Basement (habitable space): Basement (habitable space): Total square feet: Total square feet: 131 ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ _6,500.00 2. If Commercial project, what is the proposed use: 3. Source of heat: ❑Gas❑Oil❑Propane❑Solar MOther electric Fireplaces need a separate Fuel Burning Appliances & Chimney Application 4. Are there any structures not shown on the plot plan? DYES 'ENO Explain: 5. Are there any easements on the property? DYES ZNO 6. SITE INFORMATION: a. What is the dimensions or acreage of the parcel? _.22 acres b. Is this a corner lot? hYES ©NO c. Will the grade be changed as a result of the construction? DYES ONO d. What is the water source? ❑PUBLIC ©PRIVATE WELL e. Is the parcel on SEWER or a PRIVATE SEPTIC system? private DECLARATION: • I. 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 requ i red 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: 46 c` 62,t,t 2.e- SIGNATURE: /`/ DATE: G� Z`" zo