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ADDITION/ALTERATION PERMIT ..Permit#:"R- : og . Lot
-�_� :- APPLICATION . Permit Fee::$
To»m of.Quecnsbury
742 Bay Road,Queensbury,NY 12804 t "Invoice#:. �20.�
P:518-761=8256 www:gueensbUmnk"
. Project Location: 61
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Tax Map ID.#::. �5 : / . " ..3 : . Subdivision Name:
:.CONTACT INFORMATION: . .
.. A .. .licant:.
Name
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Mailing Address,..C/S/Z :�.). :: � :Lc .(2 U ..: . : -S
Cell'Phony: �61g aa9� �.��,V.T�� cS Land Line:, ( f ) q ''o 3: .Sf"
Email: Clnc v • G .(� l l onsfii��� �:bl)C_Q" ;:.CC off,
• : Pn ma,r Owner s
Names) � :. �' ���
Mai.ling.Address,.C/S/Z: . . ;
Cell".Phone: (. j- " a:and•�ine:
Email: . ►�o�. h.�e-.{>cz..f� ..C:.G�m�c.'I:� Cc v�: ' "
Check if all work will be performed.by homeowner:only .
• . . Contractor s : Workers' Comp documentation must be submitted with this application
Contact Name(s),.. . . , .��: p �i"LILC_�
Contractor Trade: - 1�e Cray f : "(� V) 1r (f" 0 c2
IVlailing.Address,..C/S/Z3 -
.Cell Ph"one:.�.. . )
Land Line:
Email: �:r '� f rJs" 1 a :f
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Business Name: �GL�I �i :�� V:�►�.. ...P� E: : . . r.. ,, , ,,�� T
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Cell::Phone ):: . Land Line: .. ( 1.9'... .)
Email:.:
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Addition/Alteration Application Revised February 2019
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• Contractor(s),-,-Workers' Comp documentation must be submitted with this application
Contact Name(s): d Div I�e1,►�i C_
Contractor Trade: Inc r'`�� C ,
Mailing Address, C/S/Z:
Cell Phone: (61< ) (3 05-3 Land Line: �)
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _�) Land Line: � )
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line: �)
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line: � )
Email: - - -�-- -- -- ---- --- -- -
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Addition/Alteration Application Revised February 2019
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PROJECT INFORMATION:
TYPE: Commercial /` Residential
WORK CLASS:
YSingle-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: /96 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): C so-co Basement (habitable space):
Total square feet: l l e' Total square feet:
ADDITIONAL PROJECT INFORMATION�:� r� 2
1. Estimated Cost of Construction: $ "if 1 J
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2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one): Gas Oil Propane Solar Other e (. `�� n
Fireplaces need a separate �ueBurning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? YES 0/ xplain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage oft el? 010 'x
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result a construction? YES NO
d. What is the water source? PUBLIC PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? C. S'ti vl-r,
Addition/Alteration Application Revised February 2019
DECLARATION:
1. 1 acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period.
2. Ifthework is not completed by the 1 year expiration date the permit may be renewed, subject to
fees and department approval.
3. 1 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. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
5. 1 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: h JO,
SIGNATURE: Ll- XJ DATE:
Addition/Alteration Application Revised February 2019