applications a 3
_ Office Use Only
ADDITION/ALTERATION PERMIT Permit#: 1 1
APPLICATION Permit Fee: $ '3O tr
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#: 1,4\2-ZSI
P:518-761-8256 www.queensbury.net
Project Location: 56 S L-it facir etti�(�j, (N ( IZ
Tax Map ID #: 2.21' • -2\ Subdivision Name: Cieve.4o4G
CONTACT INFORMATION:
• A licant:
Name(s): i Moon
Mailing Address, C/S/Z: Sp see✓1 je Ropi A `Z (boo(
Cell Phone: ( 1-5 ?- ) 3RO O,u( Land Line: (
Email: ('901eoc p Conn
• Primary Owner(s):
.+C ex -t 5.-Az a r‘r\-e 1Vkoo r\ _Il
fn�� �
Mailing Address, C/S/Z: so S-ee-k t
NoOZc�. e /Cell Phone: Os .- ) 190 o t 8 Land Line: (I ) 16 !
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): Cho-A \like
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: (
Email:
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: 1,-. 4111Gv..-5 Wik\ e=`^-1
Contact Name(s): DQ.r-pn� 4c•-�-•
Mailing Address, C/S/Z: /G61 1cJ 3 - ==y --- dens ql(S ra/
Cell Phone: ( ) Land Line: (S1E: ) 3-912' e-/c.8 ''
Email: cJan c' w+l)r0.rnsq�a( i•-15 tcro, 01e5,9ncs5
Contact Person for Building & Code Compliance: Moso ,r,
Cell Phone: ( ) Land Line: (
Email:
Addition/Alteration Application Revised February 2019
PROJECT INFORMATION:
TYPE: Commercial Residential
WOgi(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: 1st floor: 11000
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: W 00 0
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ I K
2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one): Gas Oil Pe Solar Other
Fireplaces need a separate Fuel Burning 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
6. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel? I.O9-
b. Is this a corner lot? NO
c. Will the grade be change as a result of the construction? YES ►.
d. What is the water source? PUBLIC PR ELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? ?c w c-e ScP\L
Addition/Alteration Application Revised February 2019
3 A
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: 9 e. ,J e. Isom
SIGNATURE: � DATE: `I/Lhva 1
Addition/Alteration Application Revised February 2019
-' FUEL BURNING APPLIANCE & Office Use only
CHIMNEY APPLICATION(")
\ Permit#: -fl 214.20 lei
"�
`�....-__ Permit Fee:$ 2-
Town of Queensbury k, 4 '}
742 Bay Road, Queensbury, NY 12804 Invoice:#:
P:518-761-8256 www.queensbury.net
Project Location: SO Seel. Veil 00.ee.olowil YJ' Tax Map ID#:
Room of Install: L',vw`�i1.e ivv Planned Install Date: -3unc. i ei"t 201°1
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• Applicant:
Name(s): ►-2;x 0--(da,r4
Mailing Address, C/S/Z: So 5-ee lie, ?At aaee,,,sto.rj , w-( )Z�,o`C
Cell Phone: ('7 51 ) '3q 0 o — o 11 Land Line: ( )
Email: ct., . VMccor► j . 9Ac. c ov",
• Primary Owner(s):
Name(s): SkM-b- A) Ae
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
• Installer/Builder:
Business Name: Ic Viele eon4----e4 /1-111e_ 1:-',\02_.01k(_ CoAfteort`y
Contact Name(s): t_hact Oielc / ?�.--t l c ViAmiDerg
Mailing Address, C/S/Z: .F,vse0AC(: ca. : 2 9 51 t✓ALe 5bc>re ik►.r& , LA t. Gewyyc-,rly 12b`tJ
Cell Phone: _( ) Land Line: _(61S ) 6 6 a - g3oo
Email: ?Ch n&berS 0 -14.2 4 plAC.e co.C.ov
Contact Person for Building & Code Compliance: 2Ek Mov'J
Cell Phone: ( 1 q' ) 39 v- bG 0l Land Line: ( )
Email: r'etccor.t. ,,,.tod l e S✓t,,k_o . Loy,
Fuel Burning Appliance &Chimney Application Revised March 2017
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove " Fireplace Insert Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
place,factory built**
**Manufacturer's name: `1 oit.k- CA-S'hrv.�s Model#: VC " Merctc.b
SOURCE OF HEAT: U
'/Wood Coal Pellet Gas
CHIMNEY INFORMATION:
141asonry:
block brick stone
Flue:
tie steel size, in inches
Material*:
double-wall triple-wall_insulated Alloy
(*Manufacturer's name: L ^ea-= 1-Ic>f4eSavtir lklkra Pl-0 Model #: CO9- (tS I=a )
-Telex e. LJerAica - CA54-tn)) 1nkarriM t... hiLOSQLtt d/L- Mcr`r-r cS,
ADDITIONAL INFORMATION:
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.
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 andd agree to the above:
PRINT NAME: 12e7( 0
SIGNATURE: DATE: 6/ Zoi7
Fuel Burning Appliance&Chimney Application Revised March 2017