applications Office Use Only
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f' o- ADDITION/ T -t] TE
AP L rmit Fee:$ ( :) g1 1 1)
Town of Queensbury APR O 5 )
742 Bay Road,Queensbury,NY 12804 2019 Dice#: 3 s-3
P:518-761-8256 www.queensbury.net
((��� TOWN OF QUEENSBURY
�� KODL1.5 16 DBUILDING&CODES
Project Location: -0-
Tax Map ID#: Z C 3 '3- 1 Subdivision Name:
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CONTACT INFORMATION:
• Applicant:
Name(s): ? -1 rirc ('on&- l C*t on : kvi C S LLC Mailing Address, C/S/Z: ;I R .YO a s ' ,
Cell Phone: ( 5_ SS ) 3nkt5 1+ I - Land Line: ( S j 414" )"2- Le, S
Email: `1-CO iC&, U-e cha. , ,isLi( 0) pc, CL1. ,. c a. C_C A
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• Primary Owner(s): , ('
Name(s): V IC1OR 4 LINDA l'E
Mailing Address, C/S/Z: 4S 14 i2T 15TbnJe biZWEI GkNSevao4". NY 128 '!
Cell Phone: ( 5 ) 1t /_d137&0 Land Line: ( 5 % ) 51''3-2ot
Email: -theVic.4orI P.yc&oO.COM
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): 'Pal k,t 1 O n - lzl rn- C Ofl rfl .,--t Dn SCR-V (,CS LLG
Contractor Trade: C n-c G. 1 CDIQVULC t 0 NJ
Mailing Address, C/S/Z: 25 Rai road PI , ,, (trc o a Springs , N\J 1 Z kLe LO
Cell Phone: ( rvi g ) k. U. S d 1 'I L Land Line: ( 51 K ) 414 , 3 2 Ls `b
Email: paw.\Ivamp pCC1 ttDCa, C Cc\ (t—rphwie- , Chand,l-r6 pC,SO-r gL�
**List all'additi6nal contractors on the back(of this form J
• Architect(s)/Engineer(s):
Business Name: Sea GC t" n C U. E�noy'l n r n q t-e &c n
Contact Name(s): boa() A"GIct.YYI s
Mailing Address, C/S/Z: 1 + fl4 `1"1 l l,S b1:.0V-% i C-1 .fSCV00Y- „ N\` 12- 3 a
Cell Phone: ( 6 I g ) L.Q. £S 3 0 Leto K Land Line: ( )
Email: cscacLi 9( of(3fC -CSI9n C \I C1 a rr , rwn
Contact Person for Building & Code Compliance: AQPV 1C..6yr
Cell Phone: ( ) Land Line: ( )
Email:
Addition/Alteration Application Revised February 2019
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• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): N } (, D-c o n o bum COr trot G n9 L I- L
Contractor Trade: el-cm r co ON
Mailing Address, C/S/Z: 38 AilN-Ci t R-d , porter COrn-ers,
Cell Phone: ( S ) a P Le Loci4- Land Line: (
Email: dfiflnoCon—a.CAI 1-9 9 ncu I c Corn
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): C 1-el V C l s C'1 PS con-rr GL G`-h n9 L LC.
Contractor Trade: E t C C1-121 C I .n
Mailing Address, C/S/Z: c3-4- 12 1--Ds-cna a1-e J. sKa\4 IAM , y I Zap
Cell Phone: ( 51 ) 3LQ 5 0-4-cl 0 Land Line: (
Email: ��C tit Q f-i—c011_q ( \) cU C O • corn
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): `n-C.C\ l A t - 3 p�Vo )i no n f%'1 4/
Contractor Trade: . I,� m O'I n ( '' `j1
Mailing Address, C/S/Z: i g 1\1 S 1 ()'(l c t 1 &1/1:(tt 401 , S t- a. 1Q&, 1 Zn
Cell Phone: ( ) Land Line: ( 51 g ) 5
Email: -jy-CIC\I g \D 1' SOJLtTaf' a . C�'M
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): 7Ohn RLL-1t RAN — I nc
Contractor Trade: _�1(2._ Vf
Mailing Address, C/S/Z: P O. RDX 3 , mi CCt h elkovt, , 125c5D
Cell Phone: ( ) Land Line: (
Email: dr\1 vucuut i.ioiza.rd 3 U (Imo o Corn
• 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:
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
/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: 2,3\ S'F +" 210 SF = 14liF BGL,S-ems� : Z.r 131 S r
2nd floor: i S 29`'fluor: 2 I .G1 (i) ,SF-
3rd floor: _ 3rd floor:
Basement (habitable space): 2 J y Basement (habitable space): �/
Total square feet: 14 I Total square feet: 0 7 2 7
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 51U , 5 -g 50
2. If Commercial project, what is the proposed use: (,I 0,
3. Source of Heat (circle one): e. Oil Propane Solar Other
Fireplaces need a separate Fuel Burning Appliances &Chimney Application
1
4. Are there any structures not shown on the plot plan? YES N9i Explain:
5. Are there any easements on the property? YES
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? 3 .1 AcIZEs
b. Is this a corner lot? 1113 NO
c. Will the grade be changed as a result of the construction? YES
d. What is the water source? PUBLIC PRIVATE WELL\
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? SEPPC-
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. 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: NICA4- 0,Kforw ` -P2L b etu"STrwcrlci Skruw" -- '" nn
SIGNATURE: / l��/`� DATE: v 1(° /24)
Addition/Alteration Application Revised February 2019
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gUVku Q
FUEL BURNING APPLIANCE & Office Use Only
tP CHIMNE I T-? p-rmit#: C- -U( SS 2-s 'd �?
I w 1
P-rmit Fee:$ / �o
Town of Z"C ueensbury APR 30 2019 voice:#:
742 Bay Road,Queensbury, NY 12804 -
P: 518-761-8256 www.queensbury.net TOWN OF QUEENSBURY
BUILDING&CODES__
Project Location: /6 [ale) I (s { " e Tax Map ID #:
Room of Install:. Li 'AI /D-Mivty's - Planned Install Date: Aiii -
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): Vt C fo r 6
Mailing Address, C/S/Z: nd1lS cZ t--) bOa/1 i aLf(Li 5 llfeaaCt0)1A- Dr'
Cell Phone: ( 6 5 ) ,ot _q 3 7c,2 Land Line: ( ) �c 1
Email: 1zg'31/
• Primary Owner(s):
Name(s): sac-14 C -.
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Installer/Ber: Workers' Comp documentation must be submitted with this application
Contact Name(s): Nri c2v% 1\Je Lon
Contractor Trade: -F, c,S LI-C
Mailing Address, C/S/Z: `-(Zc co gs G)OQQ-(s KM. omit
Cell Phone: _( Land Line: _( 5(g )�7ctg` 2-Z -
Email: S b WACGo vex(� c vs �cam....e. ,{e p le_ceiv -Leo--
Contact Person for Building & Code Compliance: bed octsOO)
Cell Phone: ( - ) _ - Land Line: ( ) ZZ-
Email: 5�Cw I()Ow'C. ‘ -v+712--- Vc. —co
Fuel Burning Appliance&Chimney Application Revised February 2019
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert FireplaceCt-P)
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory.built**
(**Manufacturer's name: iE-e M0t t4a Tb3(10e' Model #: � ('PP 3g-GP
SOURCE OF HEAT:
Wood Coal Pellet $. Gas propaine.)
CHIMNEY INFORMATION:
Masonry (require plans to be submitted):
block brick stone
Flue:
_tile steel _size, in inches
Material*: - ry
double-wall triple-wall insulated X ,"vo_ J9oi
(*Manufacturer's name: S-( ok43' o&) DO /L Model #: 46, V )
1. Two inspections are required. A rough-in inspection, prior to installation and a final inspection, after
installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces & chimneys require plans to be submitted.
4. Twenty-four (24) hour notification is required for inspections.
5. Workers' Comp insurance information is required with this application.
Declaration: Construction/installation must conform to NYS Fire Prevention & Building Code and/or manufacturer
requirements. The applicant or owner agrees to comply with all applicable laws, ordinances, regulations and all
conditions that are part of these requirements and also will allow the inspector to enter the premises to perform the
required inspections.
I have read and agree to the above:
PRINT NAME: E �-t'"
SIGNATURE: DATE: q 1(I
Fuel Burning Appliance&Chimney Application Revised February 2019
a'NAY v(A.Q CLvvu Vim,
FUEL BURNING APPLIANCE & Office Use Only
fr CHIM Permit#: I� `�( 'S' "?-t11 7
E
Permit Fee:$ 2-co 0 6
Town of Queensbury APR 3 0
2019 • Invoice:#: (-{7
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net TOWN OF QUEENSBURY
BUILDING&CODES
Project Location: lie d( newt v '-v1SbO`' ( Tax Map ID #:
Room of Install:- 612,,5e.P'Y — Planned Install Date:
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
•
• Applicant:
Name(s): V r c-6 6
Mailing Address, C/S/Z: k_vic([C. VcoLd, u,99_AS bv.4 I z,'Cc/ (45 k.. s-l-cm_Dr,6arkcarteI
Cell Phone: ( r ` �� Land Line: ( ` ) 17.-g3
Email:
• Primary Owner(s):
Name(s): `C c/111-e-
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Installer/Builder: Workers' Comp documentation must be submitted with this application
Contact Name(s): -v (Tt k.)L3C
Contractor Trade: t 2 P c� CL(_
Mailing Address, C/S/Z: Lf 1 s (2 c‘ti±k_ ®u V`&19tAl KA4 C8
Cell Phone: ( -- ) Land Line: ( ) 7g e. 22_26
Email: Skew✓VO C (a Ce4 el",
Contact Person for Building & Code Compliance: S-R___ IVY.
Cell Phone: ( Land Line: ( - a-2--ie
Email: S vcr a- f z sz)1 < C-o.n(1
Fuel Burning Appliance&Chimney Application Revised February 2019
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _ Fireplace Insert , Fireplaces(icod)
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built** wC
(**Manufacturer's name: Svpk.t.o r UVCT C0 Model #: ►A1 gd�
SOURCE OF HEAT:
\f-Wood Coal- Pellet _Gas
CHIMNEY INFORMATION:
Masonry (require plans to be submitted):
•
block brick stone
Flue:
tile steel size, in inches
y Material*:
_double-wall _triple-wall insulated Et45 •
(*Manufacturer's name: bUlf C(`C �_t 0 O ` Model #: JET )
1. Two inspections are required. A rough-in inspection, prior to installation and a final inspection, after
installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces & chimneys require plans to be submitted. •
4. Twenty-four (24) hour notification is required for inspections.
5. Workers' Comp insurance information is required with this application.
Declaration:Construction/installation must conform to NYS Fire Prevention & Building Code and/or manufacturer
requirements. The applicant or owner agrees to comply with all applicable laws, ordinances, regulations and all
conditions that are part of these requirements and also will allow the inspector to enter the premises to perform the
required inspections.
I have read and agree to the above:
PRINT NAME:
SIGNATURE: DATE: 'a ' 9
Revised February 2019
Fuel Burning Appliance&Chimney Application