RC-0789-2021 y 9•
Office Use Only
ADDITION/ALTERATION PERMIT Permit#: - d �• ?_f?fLQ
APPLICATION Permit Fee: $
Torn of Queensbury'•
742 Bay Road,Queensbury,NY 12804 Invoice#: _�)Z-i 6
P:518-761-8256 www.gueensburV.net
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Project Location: 00 y46in;...:�.
Tax Map ID#: ?jd� �4 " 1n Subdivision m"e: - R � - frl I
J C tE Y Y ` h
CONTACT INFORMATION: DEC 15 2020
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• Applicant' �-� T�V��Ed � `jP Fi �b;•�[ ?�6\!�
' I'Giil_rrli`� t � �
Mailing Address, C/S/Z: �jL? �-��)� �,¢<S¢ � ,;; ��, �� /�ri� �
Cell Phone: (31-1 V ) ��`1 �!�'i�, Land/Line: �)
Email: !✓Sti��l a jr7r;/��'y�,�,/ (e�t�
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PrimarV Owners :
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: � )
-- Email - _ - -- - -- -a.—
❑ Check if=all work will be performed by homeowner only
• Contractor(s):�Workers' Comp documentation must be submitted with this application
Contact Name(s): l;
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ) 4&;� ��/l 43 Land Line: � )
Email: -
**List all additional contractors on the back of this form
• Arch itect(s)/Eng!neer(s): �
Business Name:
Contact Name(s):.
Mailing Address, C/S/Z:
Cell Phone: Land Line: � )
Email:
Contact Person for Building & Code Compliance: ,Q�p�<cu_ r
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 )
i
Townhouse Business Office Retail
Industrial/Warehouse _Garage (#of cars ) _Other (describe )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2nd floor: 2nd floor: COS
3rd floor: 3rd floor: �� M
Basement (habitable space): Basement (habitable space):
,
Total square feet: Total square feet:
_ :i►DDiTiOr4AL-PROJECT-iNFORir'IATION:
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1. Estimated Cost of Construction: $ � (� i 00
2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one : Ga Oil Propane - Solar Other
Fireplaces need a separate uel Burning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? YES NO Explain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions"reage of the parcel?
b. Is this a corner lot? YES NO
c. Will the grade be changed as a res ,!.he construction? YES NO
d. What is the water source? PUBLIC. PRIVATE.; ELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? rri-t1t)I�L Jfi�rl�
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Addition/Alteration Application Revised February 2019
i
DEQLAiaATION:
1. 1 acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period. pistd ackv , � �`c►.�
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 acertificate of occupancy.
I have read and agree to the above:
PRINT NAME: (,JSI
SIGNATURE: ( �� '�. / Gwe DATE:
Addition/Alteration Application Revised February 2019
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I TOWN OF QUEENSBURY'
BUILDING DEPARTMENT g� ��, � ' � $fit;^-�,u�'•
B Sed on our limited examination,compliar
our comments shall not be construedA
incating the plans and specifications are in
fullcompliance with the Building Codes::bf
cJ`�1, ry�w York State.
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p e
TOWN OF QUEE ' Y
BUILDING & C T
�Reviewed By-
Date:
i f 11.-fir....._
KRAFT PAPER INSULATION. ? 1 �;. � t11
MUST BE COVERED BY E 4 � n � SEE ffi
NON-COMBUSTIBLE PARRIERxvdot-
I NO` i
FOAM INSULATION MUST BE
C0VERED BY A 15 MINUTE
HERMAL BARRIER sr=