CC-0066-2022 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: CC. - OOIQb- 2oZ2—
APPLICATION Permit Fee:$ 2AI.54
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
Invoice#: AZ"
P:518-761-8256 www.gueensbury.net I /I
Flood Zone? Y N Reviewed By:
Project Location: 25 Willowbrook Drive - Behavioral Health Services North
Tax Map ID#: 296.12-1-37.1 � rS0tgi e:
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PROJECT INFORMATION: TOWN OF
C UEENISBURy
BUILDING& CODES
TYPE: Residential X Commercial, Propose Use: Medical Office - current
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: 690 SF
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement(habitable space): Basement (habitable space):
Total sq ft: Total sq ft: 690 SF
Scope of work to be done:
Renovation to interior office space to create pharmacy space within the extisting offices of
Behavioral Health Services North office space. All work is interior and to non-bearing interior
walls of the existing offices,
Addition/Alteration Application Revised January 2021
i
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Behavioral Health Services North
Mailing Address, C/S/Z: 25 Willowbrook Drive, Queensbury NY 12804
Cell Phone: ( Land Line: 813 )892-0194
Email: psuarez@genohealthcare.com
Primary Owner(s):
Name(s): Behavioral Health Services North
Mailing Address, C/S/Z: 25 Willowbrook Drive, Queensbury NY 12804
Cell Phone: ( _) Land Line: 813 )892-0194
Email: psuarez@genohealthcare.com
❑ 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): TBD-project is being bid by multiple contractors-selected contractor information will be provided
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:l ) Land Line:
Email:
**Workers' Comp documentation must be submitted with this application**
• Arch itect(s)/Engineer(s):
Business Name: Rucinski Hall Architecture
Contact Name(s): Ethan P. Hall
Mailing Address, C/S/Z: 134 Dix Ave, Glens Falls NY 12801
Cell Phone: ( _) Land Line: 518 )741-0268
Email: ephall0mycamr.com
Contact Person for Compliance in regards to this project: Ethan P. Hall
Cell Phone:�_) Land Line: 518 )741-0268
Email: ephallCaD-nycap.rr.com
Addition/Alteration Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $$75,D00
2. Source of Heat (circle one).: if" propane —Solar—Other existing
Fireplaces/inserts need a separate Fuel.Burning Appliances & Chimney Application
3. Are there any structures not shown'on< he,plot plan? YES NO Explain: NA
4. Are there any easements-,on the property? YES X NO
SITE INFORMATION:
• Is this a corner lot?'. x YES -NO
• Will the grade be changed as,a result of the construction? YES X NO
• What is the water source? XTWBLIC PRIVATE WELL
• What type of wastewater.system is on,the parcel? XSEWER —PRIVATE SEPTIC
DECLARATION:
1. 1 acknowledge,that nc�'cbhstruction 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 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: Ethan P. Hall -:,Arch2pAXAaient for the Applicant
SIGNATURE: DATE: 22 Feb 2022
Addition/Alteration Application Revised January 2021
FIRE MARSHAL'S OFFICE
Tozvn of Queensbury
742 Bay Road, Queensbury, NY 12804
"Home of Natural Beauty ... A Good Place to Live "
PLAN REVIEW
BHSN
25 Willowbrook Road
CC-0066- 2022
3/2/2022
690 sf alteration
The following comments are based on a review of submittals:
• Verify fire extinguisher location and inspection
• Location of exit/Emergency lighting will need to be verified
• Verify paths of egress
• Verify storage
• Knox Box key is required for Pharmacy entry
• NFPA 72 letter of compliance required for any alterations to the fire alarm
system. Adding of appliances will require a floor plan to be submitted
• NFPA 13 letter of compliance required for any modifications to the
sprinkler system
• Contractor to exercise caution and provide protection for all fire alarm and
sprinkler devices, during construction
Michael J Palmer
Fire Marshal
742 Bay Road
Queensbury NY 12804
firemarshal@queensbury.net
Fire Marshal 's Office - Phone: 518-761-8206 - Fax: 518-745-4437
-flremarshal@queensbunj.net - zuzvzv.queensbury.net