Loading...
RC-0072-2021 4 �S r Office Use Only ADDITION/ALTERATION PERMIT Permit#: ?-C—DO'}Z— 2QZA APPLICATION ZZ.rp— —`----' Permit Fee:$ Town of Qucensbury 742 Bay Road,Queensbury;NY 12804 Invoice#: O P:518-761-8256 www.gueensbury.net Flood.Zone? Y N Reviewed By: Project Location: L9 ec y� V vi Ave- nvC, 0v��lS�j s1 GpnS Y�C�'ion Tax Map ID #: Subdivision Name: 3rJ� . ly -3 - 5q PROJECT INFORMATION: TYPE: Residential Commercial, Proposed Use: 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: 2nd floor: 2nd floor: 3rd floor: 3rd floor: Basement (habitable space): Basement (habitable space): Total sq ft: Total sq ft: 5 H oq Scope.of work to be done: 36 (neu C w ors ���`� `fie-rmis\-A wovlZ if CJVS CJW �r 3 s� -�- 1 010, D GCC 9 FEB 19 2021 TOWN OF QUEENSBURY BUILDING&CODES 'Addition/Alteration Application Revised January 2021 ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ 45 000 2. Source of Heat (circle one): KGas _Oil _Propane _Solar_Other Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application 3. Are there any structures not shown on the plot plan? YES X NO Explain: 4. Are there any easements on the property? YES X NO SITE INFORMATION: • Is this a corner lot? _YES XNO • Will the grade be changed as a result of the construction? _YES NO • What is the water source? I PUBLIC _PRIVATE WELL • What type of wastewater system is on the parcel? _SEWER /PRIVATE SEPTIC DECLARATION: 1. I acknowledge that no construction shall be commenced prior.to the issuance of a valid permit and will be completed within a 12 month period.Any changes to the approved plans prior to/during construction will require the submittal of amended plans,additional reviews and re-approval. 2. If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of Queensbury.After 1 year from the initial application date, 100%of the fee is retained. 3. Ifthe.work is not completed by the 1 year expiration date the .permit may be renewed, subject to fees and department approval. 4. 1 certify that the application, plans and supporting materials are a true and a 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. 5. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of occupancy. ,6. 1 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: SIGNATURE: DATE: o� Addition/Alteration Application Revised January 2021 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • A Imo. y Lrn:► Name(s): P�V�ll�J2' Mailing Address, C S/Z:. 1(o P6 rKv)-e w Ave--,, h N 1 d Cell Phone:� ) o�1 Land Line: Email: QMCLiI. • Primary Owner s Name(s): Mailing Address, C/S/Z: G� ©Ueu15 Cell Phone: S( 1 b -) - Land Line: �_) Email: rlveS2 all. CO Xcheck if all work will be performed by property owner only • Contractor(s): (List all additional contractors on the back of this form) Contact Name(s): Contractor Trade: Mailing Address,-C/S/Z: Cell Phone: �_) Land Line: Email: "Workers' Comp documentation must be submitted with this application" • Arch itect(s)/Eneineer(s): Business Name: Contact Name(s): . Mailing Address, C/S/Z: Cell Phone:�_) Land--Line: � ) Email: Contact Person for Compliance in regards to this project: Cell Phone: Land Line: Email: Addition/Alteration Application Revised January 2021