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applications Office Use Only 41iit ADDITION/ALTERATION PERMIT Permit#: - 0 '2^ �� APPLICATION Permit Fee: $ 500 — Town of(Zueensbury 742 Bay Road,Queensbury,NY 12804 Invoice#: I Lf2 (p P:518-761-8256 www.queensbury.net Project Location: //j// &i) at/ _ Tax Map ID #: 5231/60 314.13-1-3 Subdivision Name: EC E El 1E "iz CONTACT INFORMATION: JUN 14 2019 • Applicant: TOWN OF QUEENSBURY BUILDING&CODES Name(s): Jerk-I Cer-"enseen Mailing Address, C/S/Z: /yi Za j Rd 6 ec sh -cy, ley Cell Phone: ( 5'?" ) 3a1- 3o414 Land Line: ( 5 8 ) 795-o76 7 (w rk) Email: f dc1Jor7oP,gj ,'i• ezm • Primary Owner(s): Name(s): 1 ;:j r7ensec1 Mailing Address, C/S/Z: i�// B: � , Qgeensbw-y 1CIY /.-1 y Cell Phone: ( ) 32(-3o4'y Land Line: ( .57P ) 79?-D77 7 Email: -f' 'or-g6 �✓ 6 Cc,n ❑ Check if all work will be performed by homeowner only • Contractor(s): Workers' Comp documentation must be submitted with this application Contact Name(s): T fi, S,n; ► Contractor Trade: Genera( h. l ny Mailing Address, C/S/Z: 1174 7,0_,al'ealk, 5r NY /ao Cell Phone: (51R ) 3“0 Land Line: (,5/g- ) 344,-5,210, Email: Si-n;fit .nu,1,6orn **List all additionarcontractors on the back of this form • Architect(s)/Engineer(s): Business Name: S-fctcJwe- 120-14, 61/mere_ 1rcA, Contact Name(s): Far) (,'i nir- Mailing Address, C/S/Z: iy3 °y S+ S l,�► dr Al y J2 o5 Cell Phone: ( ,b 1? ) ( '11- 7i/ Land Line: 1518 ) 37y-9'Y/Z Email: t8IIfi° -F@ srytreh. Cowl �J Contact Person for Building & Code Compliance: '7 0 �oricnseyn Cell Phone: ( 5 ? ) -30yy Land Line: ( •c'a ) 79cr-0-74 7 ( -A ) Email: -4de1 jolt.J 901a 1 . Cerra Addition/Alteration Application Revised February 2019 J r l PROJECT INFORMATION: TYPE: Commercial y 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: 681 1st floor: 2nd floor: 2nd floor: 3rd floor: 3rd floor: Basement (habitable space): Basement (habitable space): Total square feet: al Total square feet: ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ /60) WV. oc 2. If Commercial project, what is the proposed use: 3. Source of Heat (circle one): Gas Oil Propane olar Other prss;r'e 5 / x- 24,-Jpltetsh,;e Fireplaces need a separate Fuel Burning Appliances & Chimney Application 4. Are there any structures not shown on the plot plan? YES VOA Explain: 5. Are there any easements on the property? YES 6. SITE INFORMATION: a. What is the dimensions or acreage of the parcel? 5— b. Is this a corner lot? YES VOA c. Will the grade be changed as a result of the construction? YES Ib d. What is the water source? PUBLIC` PRIVATE WELL e. Is the parcel on SEWER or a RIVATE SEPTIC ystem? ?iraI° sepf`G Addition/Alteration Application Revised February 2019 • 16. 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: 7 c ,„j��,;, n SIGNATURE: 7'L� DATE: 6 /a/19 l Addition/Alteration Application Revised February 2019 FUEL BURNING APPLIANCE & office use only IOW CHIMNEY APPLICATION Permit#:¢-C- O 1-' 2--(:)Aci Permit Fee:$ Trnrn of(Ipccnshun• 742 Bay Road, Queensbury, NY 12804 Invoice:#: P:518-761-8256 www.queensburv.net Project Location: PI / Bi� _ I 2c_ _Qu/t4,141',,Tax Map ID #: 5;23160 16. 13--/ Room of Install: 54.,J1 Planned Install Date: 3ep errs ber 09015 **ONE APPLICATION PER APPLIANCE** CONTACT INFORMATION: • Applicant: Name(s): �cdd �T r-1e eci Mailing Address, C/S/Z: 73L i y i CL Cell Phone: ( vr ) 3 '-f`1 t -3o `j t Land Line: (5- $ ) 798 b7 i 7 (cc)) Email: 1addL o r j ottv ei rria,;( . • Primary Owner(s): Name(s): 7'c �ra ralense n Mailing Address, C/S/Z: Ray 1Z—cl Cell Phone: _( ,c e' ) 3�1 - 3c / -/ Land Line: _(SL? ) ?9�'- _7E,7 () Email: limid Jcrjc G �-{w ,l ,corm J ❑ Check if all work will be performed by homeowner only • Installer/Builder: Workers' Comp documentation must be submitted with this application Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: _( Email: Contact Person for Building & Code Compliance: Cell Phone: ( ) Land Line: ( Email: Fuel Burning Appliance&Chimney Application Revised February 2019 FUEL BURNING-APPLIANCE INFORMATION: TYPE OF DEVICE: X( Stove Fireplace Insert Fireplace Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3) Fireplace,factory built** (**Manufacturer's name: Model #: SOURCE OF HEAT: Wood Coal )(Pellet Gas CHIMNEY INFORMATION: Masonry (require plans to be submitted): block brick stone Flue: tile steel _size, in inches Material*: double-wall triple-wall insulated (*Manufacturer's name: Model #: 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. 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: /Oda \-)celerWil SIGNATURE: DATE: 6/4/c) Fuel Burning Appliance&Chimney Application Revised February 2019