CC-0800-2019 Office Use Only
j ADDITION/ALTERATION PERMIT Permit#: CC 'EftO Pc1T_
APPLICATION Permit Fee:$
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256. www.gueensbury.net p / �
Project Location: /�S S4. 1L�. % , /._. 0cp &UIt- /)y ld0 V5
Tax Map ID#: a �. � .Z — l �Z� Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s): /6 0S
Mailing Address, C/S/Z: 145V 9 U
Cell Phone: _ ( 5/ ). 3 Z 1 910 -7'� Land Line: 51 f ) "7 93 3) 9i a
Email:- L�'11L�J lUr (® Q.6/ • LA—ye-)
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
10/Check if all work will be performed by homeowner only
• 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: I� tr-z 17E� rw xxr
Email: W i= u 11
"List all additional contractors on the back of this form DEC 0 20;9
Architects) Engineer(s): T01fl/fd O-1-i;
Business Name:
Contact Name(s): -
Mailing Address, C/S/Z:
Cell Phone: �_) Land Line: �)
Email:
Contact Person for Building & Code Compliance: ta-tVL.4- 4,14111 '�DoL,&
Cell Phone: (5)8 ) 3 ZI - ?u Line: -7 C.,-7U5-_
Email:
Addition/Alteration Application Revised February,2
i s
t� it
®__Contractor(s):_Wor_ker_s'_Comp_.do-cumentation_m.ust_be_submitted_with_this--ap.plication____.._.._
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Contractor(s): Workers' Corrip 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 submi ed with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line: A )
Email:
• Contractor(s): Workers' Comp documentation mus be submitted with-this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land ine: � )
Email:
• Contractor(s): Workers' Comp documental ion 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 doc mentation must be submitted with this application
Contact Name(s):
.Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Addition/Alteration Application Revisecifebruary 2019
7 .
PROJECT INFORMATION:
TYPE: _1 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 FOOT ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor: �1 D S
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basemen (habitable space): Basement (habitable space):
Total square feet: Total square feet: ' 00
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 4 TIo ) Dbu
2. If Commercial project, what is the proposed use: C>YiVty'4-i Yy-hm Ev
3. Source of Heat (circle one): Gas Oil Propane Solar Other
Fireplaces need a separate Fuel Burning Appliances &Chimney Application ?QC— we,,l t L)OTS,
4. Are there any structures not shown on the plot plan? YES Explain:
5. Are there'any easements on,the property? YES
-----
a. What is the dimensions or acreage of the cel.
b. Is this a corner lot? 'YES 0
c. Wild the grade be changed as a res of the construction? YES NO
d. What is the water source? PUBLIC PRIVATE WELL
e. .Is the parcel on SEWER or RIVATE SEPTIC system?
Addition/Alteration Application Revised February 20D
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. 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 priorto issuance of a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: �p�
SIGNATURE: 411-1-4A A-A-ZOJO - DATE: 1-419h
Addition/Alteration Application Revised February 2019
TOV N OF j
i..ri E II` Q 0 BUILD oo Reviewed 051
0. 2019
; I
M E Date: NOTICE f
LEVER HANDLES REQUIREb_., %tF''4'' I
1^ 10NALLPASSA
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c WHETHER INTERIOR OR
o
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TOWN OF QUEENSBURY _.
BUILDING DEPARTMENT FILE COPY C
Based on our limited examination,compliance _with our comments shait not be construed as
indicating the plans and specfications are in
full compliance,with the Building Codes of
New York State,
288.12-1-21 CC-0800-2019
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