RC-0675-2022 f
a Office Use Only
_ ) ADDITION/ALTERATION PERMIT Permit#: C 2022_
Town ofQueensbury APPLICATION permit Fee:$ 22�
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Invoice#:
Flood Zone? Y Reviewed B�
Project Location: 6 �,r�U rS
Tax Map ID M Subdivision Name:
PROJECT INFORMATION: D C Q
C. -
L,,66!D')1'1 0 2122
TYPE: Residential ❑ Commercial, Proposed Use:
1iQ 7���®P JRY
Nn 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: �A&)p �-y��
Addition/Alteration Application Revised June 2022
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ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ f,
2. Source of Heat (circle one): EJOGas ❑ 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 IiNO
• Will the grade be changed as a result of the construction? ❑ YES C16V0
• What is the water source? I OUBLIC ❑ PRIVATE 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-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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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:
� � dY
SIGNATURE: DATE:
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 4(1t,- e44- ✓'
Mailing Address, C/S/Z: 4- V0A d' &4
Cell Phone: Land Line: -
Email: &b rZe m4 r C
• Primary Owners :
Mailing Address, C/S/Z:
Cell Phone: ( t� ) �` ��_ ._ 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): /PA,0 i�Vv
Contractor Trade: C y(,�,, I,, /t2c-6G\:,, _
Mailing Address, C/S/Z:
Cell Phone: Land Line: �)
Email:
**Workers' Comp documentation must be submitted with this application**
• Architect(s)/Engi 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: �d &'A
Cell Phone: ( fit ) Land Line: �)
Email: IM, zv-. rc-e—
Addition/Alteration Application Revised June 2022
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TOWN OF UEENS URY
BUILDING EPART ENT rp U,
Based on our limited s�,.t,e
with our comments all not Fcons u d asindicating the plans nd spe a e in �-full compliance with the Bud f La 7
New York State. o
X
A
IJ 1 RE G
01
V
NOV 0 7 2022
O
BUILDING a, CODES
T F CRIEEWSPUR
BUILDING & CO EB EPTo
Reviewed By, p -
Date:
IJO
12 �
TOWN OF QUEENSBURY
BUILDING DEPARTMENT
Based on our limited examination,compliance
with_ouLcorroments shall not be construed as
indicating the plans and specifications are in
full compliance with the Building Codes of
—New York-State. " Lx
1Lr
T-OWN OF QUEENSBURY
BUILDING & CODES DEPT.
Reviewed Y.
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