RC-0293-2023 Office Use Only
J ADDITION/ALTERATION,_PERMIT permit#: (ZC- G29�'S �Z'3
Town ofQucensbury APP;LICATOk'"' `; I' 11 I 2 a y
742 Bay Road,Queensbury,NY 12804 i ° i
I' Permit Fee:$ Z - O
P:518-761-8256 www.queensbury.net � � Invoice#: G((O
III11 ;"�I' F+ '::t-HN31L."ply Flood Zone? Y QV Reviewed Bv(
Project Location:
Tax Map ID#: 3Oa. — ( C� 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: :T7t'S �- L( t re55
Addition/Alteration Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $
2. Source of Heat (circle one): ❑ Gas ❑ Oil ❑ Propane ❑ Solar ❑ Other: AZA
Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application
3. Are there any structures not shown on the plot plan? .❑ YES ` NIO Explain:
4. Are there any easements on the property? ❑ YES ` NO
SITE INFORMATION:
• Is this a corner lot? ❑ YES )SkNO
• Will the grade be changed as a result of the construction? ❑ YES r�CR10
• What is the water source? ,PUBLIC ❑ PRIVATE WELL
• What type of wastewater system is on the parcel? KJISEWER . ❑ 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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 area 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: ( J �>�,���n DATE:'SI
J
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): :v-, m 6411 f
Mailing Address, C/S/Z1 i�_� ►�1�sbe�ry LCc/ C� c.r���S�c>c rT lU h� YI�/
Cell Phone: Land Line:
Email:
• Primary Owner(s):
Name(s): {-I„ C
Mailing Address, C/S/ tVeW rs, 0 0,a �� ,{r► �; ,, w /��)V
Cell Phone: (S—cam ) 3 I— I (o L nd Line: )
Email: ohoLff, n Ca22 I
❑ 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): f's ed, M ` A q ey
Contractor Trade:
Mailing Address, C/S/Z: G ltwf J-,I s //V V_ J
Cell Phone: -,(,D — b Land Line: � )
Email:
**Workers' Comp documentation must be submitted with this application**
• Architect(s)/Enginieer(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 June 2022
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TOWN OF QUEENSBURY
BUILDING DEPARTMENT _ P T
Based on our limited examination,comp na e ��
wi!h our comments shall not be construed as
in.,oicating the plans and specifications are 0n
f- l? -compliance with the Building Cods Hof
New York State. a
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n a
n TOWN OF QUEENBURY
BUILDING & CO ES ® PT. i
Reviewed
r � ® awed ys
Date:
308.7-1-19 RC-0293-2023
Knill, Tim & KellIT
42 Westberry Way
Egress window
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