CC-0475-2022 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: C. OOC'�t Z-0 2-Z-
APPLICATION Permit Fee:$ ZID 0
742 Bay Road,Queensbury,NY 12804 Invoice#: t'2A0,-1
P:518-761-8256 www.clueensburvaiet
Flood Zone? /Y Reviewed B
Project Location: /9 3 41 /E)
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Tax Map ID#: -_? 7,9. 2 Subdivision Name: DO E-or,
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PROJECT INFORMATION: JUL 2 12022
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TYPE: 11 Residential Commercial, Proposed Use:
1:1 Single-Family El Two-Family El Multi-Family(#of units_) 0 Townhouse
El Business Office 1K Retail 0 Industrial/Warehouse 0 Garage(#of cars
El Other(describe
ADDITION SQUARE FOOTAGE:
ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor.
211 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: 6F- /o -5 6,
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Addition/Alteration Application
Revised March 2022
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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 .® NO Explain:
4. Are there any easements on the property? ❑ YES M NO
SITE INFORMATION:
• Is this a corner lot? 19 YES ❑ NO
• Will the grade be changed as a result of the construction? ❑ YES ® NO
• What is the water source? ❑ PUBLIC ® PRIVATE WELL
• What type of wastewater system is on the parcel? ❑ SEWER .19 PRIVATE SEPTIC
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DECLARATION:
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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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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. If the 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 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.
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5. 1 acknowledge that prior to occupying the facilities proposed 1, or my agents, will obtain a certificate of
occupancy.
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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.
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I have read and agree to the above:
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PRINT NAME:
SIGNATURE: DATE: _7 ;{
Addition/Alteration Application Revised March 2022 a
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): �
Mailing Address, C/S/Z: /,Z 6 9 .Q. Jr /eO-
Cell Phone: (-S�8 ) .3719 c9 O_J!22 Land Line: A
Email: ra►&-o -Ph 0
• Primary Owner(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): &e2v7/,-1/G--:tom S.'IZZ45D C)Og �s//.9�t/ GLG
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone: (.h 18 l 741i�, - y7R67 Land Line:
Email: _ 5ov 77' Ar»u•; / , C_'dr�
"Workers' Comp documentation must be submitted with this application**
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• Architect(s)/Enizineer(s):
Business Name:
Contact Name(s)•
Mailing Address,C/S/Z:
Cell Phone:�_} Land Line:
Email: m
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line:
Email:
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Addition/Alteration Application, Revised March 2022
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