CC-0694-2021 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: CC-- Occ54' Zo21
APPLICATION Permit Fee: $ 2CO
Town ofQueensbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.gueensbury.net
Flood Zone? Y N Reviewed By:
•Project,Location: S Lvl
Tax Map ID#: �-16 Subdivision Nane_: `
PROJECT INFORMATION:
TYPE: ❑ Residential I( 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: 3 1st floor:
2nd floor: 2nd floor-:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total sq ft: 3
Total sq ft:
I LI 0,
Scope of work to be.done: ' � - �- ......
S ;. j, s I
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BUILDi
Addition/Alteration Application Revised January 2021
CONTACT INFORMATION:-PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: /
Name(s):
Mailing Address S Z: 5,� 'F-' f� i W-"41ki (�'' 5
C/ /
Cell Phone: (gig ) 2-1-3 5 L- ; 4�- Land Line:
Email: ac nJt<e. i — �-Qy -et6[0q `01'1.'�'��(
• Primary Owner(s): .;.
Name(s): 'TA f ,g:5
Mailing Address, C/S/Z: '' °o
Cell Phone:�_) Land Line: �!)
Email: t7 PL �5' ' ' (:k
o 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"
• Arch itect(s)/Engineer.(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: �_) r Land Line:., ( )
Email: fj
Contact Person for Compliance in regards to this project: po�lhr i .p o'�T—
Cell Phone: �_) Land Line:
Email:
Addition/Alteration Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $
2. Source of Heat (circle one): gGas ❑ 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? ❑ YESN0. Explain:; ,
i:::.:,..: .
4. Are there any easements on the property? ❑ YES NO-
SITE INFORMATION:
• Is this a corner lot? ❑ YES eN 0
• Will the grade be.changed as a result of the co struction? ❑ YES. NO _.
• What is the water source? ❑ PUBLICPRIVATE 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-ap'proval.
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. If the 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:'
PRINTNAME: Rojo j L,u\r n QrA
S, w
SIGNATURE: � /� DATE:
``' '
Addition/Alteration Application Revised�hr ua'N 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 .
C93 Consulting (Joe Biss)
553 Route 149
CC-069.4-2021
9/13/2021
The following comments are based on a review of submittals:
• Show fire extinguisher location and inspection
• Show location and operation of exit/Emergency lighting, including exterior
emergency lighting
• Lock/ latches shall comply with Chapter 10 of 2020 IFC.
• CO'detectionis required; if source is present
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
fireniarshal@queensburt:t! iet wzvzv.queensburi!net