RC-0788-2021 Office Use Only
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ADDITION/ALTERATION
PERMIT Permit#: f?c-0'+SS 20zl Permit Fee:
. 4APPLICATION $
Invoice#: � yh
742 Bay Road,Queensbury,NY 12804 �-
P:518-761-8256 www.aueensbury.net Flood Zone?Y N Reviewed By:
Project Location: 5 Chestnut Road,Lake George
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Tax Map ID#: Subdivision Name: 289.13-1-7 b
OCT 25 2Q21
Towiv OF 0U
PROJECT INFORMATION: eU1LDIRIC$C'V813
- COD l
TYPE:_X_Residential Commercial, Proposed Use:
_X_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: 12 X 6
2"d floor: 2nd floor:
3rd floor: 3rd floor:
Basement(habitable space): Basement(habitable space): Total sq ft:Total sq ft 72 sq.ft.
Scope of work to be done:Enclosure of previously existing enclosed porch.Addition/Alteration Application Revised
January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $1650.00
2. Source of Heat(circle one):_Gas_Oil_Propane_Solar X Other�t-'
Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application
3. Are there any structures not shown on the plot plan?_YES-X—NO Explain:_
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Steve and Tracey Bureau
Mailing Address, C/S/Z:_5 Chestnut Road—Lake Geoge NY 12845
Cell Phone: 518 )_260-3177 Email: tbureaufitfun@gmail.com
Primary Owner(s):
Name(s): Same
Mailing Address, C/S/Z:
Cell Phone: f— _) Land Line: .L
Email:.
XX❑ 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): NONE
Contractor Trade: ,
Mailing Address, C/S/Z:
Cell Phone: L Land Line: L _)
Email:
**Workers' Comp documentation must be submitted with this application**
• Arch itect(s)/Enei nee r(s):
Business Name: Rucinski Hall Architecture
Contact Name(s): Ethan Hall
Mailing Address,134 Dix Avenue, Glens Falls, NY 12801 C/S/Z:
Cell Phone: L Land Line: (518 )_741-0268
Email:ephall@nycap.rr.com`
Contact Person for Compliance in regards to this project: Same as above. Ethan Hall and Steve and
Tracey Bureau.
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): NONE
Contractor Trade:
Mailing Address, C/S/Z:
_Cell Phone: Land Line:
Email:
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
4. Are there any easements on the property?_YES X NO
SITE INFORMATION:
Is this a corner lot?_YES_X_NO
Will the grade be changed as a result of the construction?_YES X NO
What is the water source? PUBLIC X PRIVATE WELL
• What type of wastewater system is on the parcel?_SEWER X 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. Ifthe 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-builtsurvey by a licensed land surveyor of all newly
constructed facilities prior to issuance of acertificate of occupancy.
I have read and agree to the above:
PRINT NAME:_Steve and Tracey Bureau
SIGNATURE: DATE:_10/21/2021
Addition/Alteration Application Revised January 2021
r 4 FILE COPY
.J
IBS Septic&Drain Service,Inc.
2 Lower Warren Street
Queensbury,NY 12804
PHONE: (518)798-8194
FAX: (518)798-3213
NOTE: Septic systems are under ground making it impossible to state with
certainty their overall condition. All systems require regular maintenance such
as pumping. No one can predict when a system will fail. This report comments
only the functioning ability on the day of the inspection and is not a warranty.
SEPTIC SYSTEM REPORT
Name and address:
Save �- V�'a�-Ce 'vr eQv
Type of system• /� l
Was tank pumped recently? If so,when?
Was the house occupied at the time of inspection?
If no,how long has the property been vacant?
Was there evidence of overflow at leach fields: effluent surfacing,black mold,
dye breakout,odor,marshy areas,depression,sign of recent se icing(lawn
disturbed)? If yes,circle those that apply and explain
To
e&;' I-���` `� � /
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Was there sewer gas noticeable in the house?A/®
Was there evidence of prior sewer backup? If yes,please explain. 1410
After running water for several minutes,was there evidence of possible backup?
Is further analysis recommended?If yes,please explain./�
Additional Comments: �
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Signature
Date �' ��