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
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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