CC-0133-2021 Office Use Only
ADDITION/ALTERATION PERMIT Permit#:_
APPLICATION Permit Fee: $ 2 .
Ibivn ofQucensbar7
742 Bay Road,Queensbury,NY 12804
Invoice#:
P:518-761-8256 www.gueensburV.net
Flood Zone? Y N Reviewed By: .
Project Location:
Tax Map ID #: 36 S � 2C) 3, 5 Subdivision Name:
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: (C .
211 floor: Floor:
3rd floor: rd -OOr:
Basement(habitable space):r Basement (habitable space):
Total sq-ft: 'Total sq ft:
Scope of work to be done: /
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DECE91WE
MAR 2 2 2021
TOWN OF QUEENSBURY
BUILDING&CODES
Addition/Alteration Application Revised January 2021
1«.�i.r1
ADDITIONAL PRO ACT INFORMATION:
1. Estimated Cost of n: $ ����®, oe
2. Source of Heat (circle one): _Gas _Oil _Propane _Solar X Other
Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application
3. Are there any structures not shown on the plot plan? YES XNO 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? A PUBLIC _PRIVATE WELL
• What type of wastewater system is on the parcel? XSEWER _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 rc 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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:
SIGNATURE: DATE: ✓��� ��Z,/
Addition/Alteration Application Revised January 2021
a
CONTACT INFORMATION: PLEASE-PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: ,
Name(s): IV411A
Mailing Address, C/S/Z: �(`� �' ,t�',. /zoV 7
Cell Phone: (.le9 ) ��i�-. /, Land Line: 0
Email:-
Primary Owner(s):
Name(s): e—
Mailing Address, C/S/Z:
Cell Phone: Land Line: ( )
Email:
R check if all work will be performed b property owner only
p Y p p Y �f'.
• 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"
• Architect(s)/Eneineer(s):
Business Name:: /41V
Contact Name(s):
Mailing Address, C/S%Z:
Cell Phone: ( ) Land Line: ( )
Email:
Contact.Person for.Compliance in regards-to this project: l7��✓ �`f
Cell Phone: - ( 76 Land Line: ,576 ) 236 260-0
Email:— 9(e 4 s
Addition/Alteration Application Revised January 2021
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• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): 45;rAO �
Contractor.Trade: �, ��� A, 011, �l`, ���� pIrGV?<
Mailing Address, C/S/Z: /ao 5;,g VdY4 011.fy P 61vco :<V/4 5cez -
Cell Phone: 576 Land Line:
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s)! C,140-0 ��-�� r on '/;vt
Contractor Trade: r`oor"W{
Mailing Address, C/S/Z: 2-057 41V-54-w 6-1/- Co.2vwe S,, Al
Cell Phone: Land Line:
Email:
• Contractor(s): Workers' Comp documentation.must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing.Address, C/S/Z:
Cell Phone:. Land Line:
Email:
• Contractor(s): Workers" Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
.Cell Phone: Land Line:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Addition/Alteration Application Revised January 2021