CC-0730-2021 k
Office Use Only
ADDITION/ALTERATION PERMIT Permit#:CC. -'O--'�- ZOfL 1
APPLICATION permit Fee: $__?_pri -
Town of'Queensbury
742 Bay Road,Queensbury,NY 12804
Invoice#:
P:518-761.8256 www.gueensbury.net
Flood Zone? Y N Reviewed By:
Project Location: �" -�� 0,4 (Z.A NaI
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Tax Map'ID#: Subdivision Nam E C E Q V E
. 12- D
PROJECT INFORMATION: OCT 0 4 2021
TOWN OF QUEENSBURY
BUILDING&CODES
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 s Basement (habitable space):
Total sq ft: ( Total sq ft: r�
Scope of work_to be done:
trill
V6,
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Addition/Alteration Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $
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 )IC NO Explain:
4. Are there any easements on the property? —YES NO
SITE INFORMATION:
• Is this a corner lot? YES NO
• Will the grade be changed as a result of the construction? YES ,NO
• What is the water source? C PUBLIC PRIVATE WELL
• What type of wastewater system is on the parcel? SEWER 4 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-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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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:
Addition/Alteration Appli tion Revised January 2021
I
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: /J
Name(s): ��i�S ,e,.
Mailing Address, C/S/Z:
Cell Phone: (S/ 2 ) Co Land Line:
Email: ' P c—
Primary Owner s
Nam
Mailing Address; C/S/Z: Z. /
Cell Phone: ) Land Line:
Email: 1a+� 0 a®1• C004
❑, 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)/Enei nee r(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 January 2021