application Office Use Only
ADDITION/ALTERATION PERMIT Permit#: P-r—' (o -Z02 O
lb"n uLCZtcensGtin• APPLICATION Permit Fee:$ 2dy
742 Bay Road,Queensbury,NY 12804 �C�� �►
P:518-761-8256 www.gueensbury.net Invoice#:
Project Location
Tax Map ID#: Subdivision Name: I I
a I! DEC o a 2020
CONTACT INFORMATION:
• Applicant: 1!1'1I I
Name(s):�C7�n= ��2C1/ice _ .r__C-_1.:s:._:.
Mailing Address,C/S/Z: _,-
Cell Phone:_(S/c'5 ) 3G/-Z94.3 Land Line: _(51,9
Email:
• Primary Owners :
Name(s): Ri G pu2� 3W36
Mailing Address,C/S/Z— �30 /NRB �L, 45Wc�6• -Op7�f"-
Cell Phone:_( )6P3 50 S Land Line: _(
Email:
,�j �ij7,?/L• COS
❑ Check if all work will be performed by homeowner only
• Contractor(s):
Contact Name(s): f�oz�tJ.
Contractor Trade:
Mailing Address,C/S/Z: /a9 Q cam/
Cell Phone:_( ) Land Line: _( 616 ) '799 o?49tt
Email:
"List all additional contractors on the back of this form
Architects)/Ensineer(s):
Business Name:
Contact Name(s):
Mailing Address,C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Building&Code Compliance:
Cell Phone: ).3(1-A)�13 Land Line: _( )
Email: e Azz'U1/V:9•
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: ❑ Commercial Residential
WORK CLASS:
❑Single-Family ATwo-Family ❑Multi-Family(#of units )
❑Townhouse ❑Business Office ❑Retail ❑ Industrial/Warehouse
❑ Garage(#of cars 4—) ❑ Other(describe )
ADDITION SQUA 4FTAIGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2"d floor: 2nd floor:
3rd floor: 3rd floor:
Basement( bita•le space): Basement(hab' �
Total square feet: Total square feet:
ADDITIONAL PROJECT INFORMATION:
Ob
1. Estimated Cost of Construction:$ _gH -
2. If Commercial project,what is the proposed use:
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? DYES ONO Explain:
5. Are there any easements on the property? DYES ONO
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel?
b. Is this a corner lot? DYES ONO
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?
Addition/Alteration Application Revised February 2019
DECLARATION:
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. 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:
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SIGNAT E: DATE: ,�J
Addition/Alteration Application Revised February 2019