RC-0584-2021 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: 2e2.1
APPLICATION Permit Fee:$ z2-0
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
Invoice#: O`D5
P:518-761-8256 www.czueensbury.net
Flood Zone? Y N Reviewed By:
Project Location:
Tax Map ID#: 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:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement(habitable space):
Total sq ft: Total sq ft:
Scope of work to be done:
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AUG 0 9 2021
TOWN OF QUEENSBURY
BUILDING&CODES
Addition/Alteration Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ZED
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 AO Explain:
4. Are there any easements on the property? YES AO
SITE INFORMATION:
• Is this a corner lot? _YES NO
• Will the grade be changed as a result of the construction? _KPR
NO
• What is the water source? _PUBLIC _PRIVATE WELL
• What type of wastewater system is on the parcel? _SEWERTE 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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 prior to issuance of certificate of occupancy.
I have read and agree to the above:
PRINT NAME:
SIGNATURE: DATE: Z
Addition/Alteration Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): C 1-h21 S a u-r&a-
Mailing Address, C/S/Z: Ll N I L 0 C kL�4 nM�rJ i2n,<J� \3N L?'
Cell Phone: Land Line: � )
Email: (' z�5( -6,4�ic2���z�-c f-. �o✓�I
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line: � )
Email:
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(sVEneineer(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: Cv,,s 6cky,(-k..e.V
Cell Phone:�_) Land Line:
Email:
Addition/Alteration Application Revised January 2021
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252.48-1-30 CC-0584-2021
Boucher, Chris
44 Top of the World
Residential Alterations (fire damage)
TOWN OF QUEENSBURY
BUILDING & CODES DEFT°
Reviewed By pl
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