RC-0069-2021 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: Q'�-'�4laG 2021
APPLICATION Permit Fee:$ 22,�
742 Bay Road,Queensbury,NY 12804 Invoice#: T—
P:518-761-8256 www.aueensbury.net
Flood Zone? Y N Reviewed By:�
Project Location: ze> (DIV
Tax Ma ID#• 2- 2— 1 'l Z- Subdivision N e o o !�\
p alp � Name: �(/ I�
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): S06
Total sq ft: Total sq ft: too
Scope of work to be done:
O C�1/1_ S S l� L n c�o w o lol U
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ECERVE
FEB 1 8- 2021
TOWN OF QUEENSBURY
BUILDING&CODES
Addition/Alteration Application Revised January 2021
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ADDITIONAL PROJECT INFORMATION: ]{
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1. Estimated Cost of Construction: $ l5'- 600e
2. Source of Heat (circle one): Gas _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 Y NO Explain:
4. Are there any easements on the property? YES NO
SITE INFORMATION:
• Is this a corner lot? YES NO
• Will the grade be changed as a result of the construction? YES NO
• What is the water source? PUBLIC _PRIVATE WELL
• What type of wastewater system is on the parcel? _SEWER PRIVATE SEPTIC
DECLARATION:
1. 1 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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. Ifthework 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 atrue 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 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: ckQS r
SIGNATURE: 02ZDATE: 2- / o9
Addition/Alteration Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): L.L G�
Mailing Address, C/S/Z: ��l ��`�� 4 U-e-- So y-�n 6Weos Pi.G S , �✓S� ,ill
Cell Phone: S'( ) 3 (—� (a.�� Land Line: 5l
Email:
• Primary Owners
Name(s): az
Mailing Address, C/S/Z: =1 d,
Cell Phone: (,-S-i P ) 9,2 .33 / Land Line:
Email: 0 VC01 06 C0 rh
❑ Check 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): (�,1GU�Gi b i L.C�tVILtS C�
Contractor Trade:
Mailing Address, C/S/Z: V&- s6c9 (7 ,-4
Cell Phone: Land Line: (.4((�e'
Email: r/ G(��se- f�Ji(c/�p .(J�/ G� _ R _Co�✓!�
"Workers' Comp documentation must be submitted with this application"
• Architect(s)/Engi nee r(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line: �)
Email:
0
Contact Person for Compliance in regards to this project:
Cell Phone: (, 7W ) 3(V-2 s-6 Land Line:
Email: r— I cjAase 0 O c lgdej�A,4 -18
Addition/Alteration Application Revised January 2021
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BY VAN DUSEN & STEVES
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IN DRAWER 17 FOLDER 2
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Date DULY 2008
MAP OF A SURVEY MADE FOR
CARROLL E. & BARBARA M. WINCH
scale 1*-41Y
BY VANDUSEN & STEVES
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DATED SEPTEMBER 5, 1991 IN FEET1 inch = 40 fiw c
MAP OF A PROPOSED MODIFICATION
TO OVERLOOK AT HILAND
DATED JANUARY 14, 1998
BY VAN DUSEN & STEVES SHEET 1 OF 4
OVERLOOK
at Hiland Park
LAND SURVEYORS, LLC DwG. No. 86672 r-loa,2
D-164
290.62-I-2 I /46-6-35