RC-0347-2022 Office Use Only
ADDITION/ALTERATION PERMIT Permit#:
APPLICATION Permit Fee:$ 220
Town ofQueensbury
742 Bay Road,Queensbury,NY 12804
Invoice#:
P:518-761-8256 www.gueensbury.net
Flood Zone? Y N Reviewed By:
Project Location: ✓� �t f z �1,�
Tax Map ID#: �r� —Z�Cj' Subdivision Name:
PROJECT INFORMATION:
TYPE: L/ Residential ❑ Commercial, Proposed Use:
Single-Family ❑ Two-Family ❑ Multi-Family(#of units_) ❑Townhouse
❑ Business Office ❑ Retail ❑ Industrial/Warehouse ❑ Garage (#of cars )
OLD ther(describe
ADDITION SQUARE FO AGE: ALTERATION SQUARE FOOTAGE:
1st floor: �°� 1st floor: r�®��
2nd floor: b 2"d floor: Ri'�1tJ �dJh�► „� p
3rd floor: 3rd floor:
Basement(habi a space): Basement (habitable space):
Total sq ft: S SF Total sq ft:
Scope of work to be done:
OZ
3/S--- _37f '7216
Addition/Alteration Application Revised March 2022
T �
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 36D
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 ❑ NO Explain:
4. Are there any easements on the property? ❑ YES ❑ NO
SITE INFORMATION:
• Is this a corner lot? ❑ YES .r NO
Will the grade be changed as a result of the VPRIVATE
ruction? ❑ YES NO
• What is the water source? El PUBLIC WELL
• What type of wastewater system is on the parcel? ❑ SEWER �IVATE 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 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 priorto issuance of certificate of occupancy.
I have read and agree to the above:
PRINT NAME:
SIGNATURE:-IA DATE: S-
Addition/Alteration Application Revised March 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): /I J gV&yU ceelnn OA
Mailing Address, C/S/Z: 16 -S�j 9/jZ4 T Lv,P�
Cell Phone: 1;K- ) �7R--'710 Land Line: �)
Email: AW 1A C,)00VY)yllA1 k 4Q E 41 ) ajv,
Primar Owners
Name(s):
Mailing Address, C/S/Z: 3 Yt LIF sou!)Cell Phone: f,�� ) � �f 9� (n Land Line: �
Email:
Z"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):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line:
Email:
**Workers' Comp documentation must be submitted with this application**
• Architect(s)/Engineer(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 March 2022
2422
OF auseNSMIR
TOgUyLD�NO&CCI��S _: ...
289.6-1-20 RC-0341-2022
Kennedy, 3oseph/Meghan O'Connor
34 Nacy Rd
Egress Window
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N S)B U RY
TOWN OF E
'nor DEpT.
13UILDING & Es
Revie-,xE d
Date'
(3 ®c
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NOTICE:
Smoke detectors are required in bedrooms,
adjacent to bedrooms and on each floor TOWN 0!--
level including cellar or basement. BUJLDlJ\j'
G QUEENBURY
6�sed on our limi�e(j exan-,;n�.
All smoke detectors & carbon monoxide with our cornnieritc,
detectors shall be Interconnnected with Lion,compliance
flot
indicating file Plans )e construed as
battery backup and located on all levels. full complian(.-e 'iu)"ih
. w -,Iff,'ifications are in
New York
Carbon monoxide deOctors are required rk sfa2La. dinq Codes of
outside sleeping areas and do all levels.
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