AST-0727-2021 • _l
Office Use Only
ADDITION/ALTERATION PERMIT Permit#: 4L -I ,i - 012-- '202-1
APPLICATION Permit Fee: $ 2-a0
Town of Quecnsbury
742 Bay Road,Queensbury,NY 12804
Invoice#: 4uo
P:518-761-8256 www.queensbury.net
Flood Zone? Y Reviewed By:&W
Project Location: Z1�
Tax Map ID#: !'01i, 14 ,, ZZ Subdivision Name: 2 2�g
p 15 tE 'E
PROJECT INFORMATION: OCT 0 4 2021
TOWN OF QUEENSBURY
TYPE: Residential Commercial, Proposed U'se: BUILDING&CODES
_Single-Family _Two-Family Multi-Family(#of units ) —Townhouse
Business Office _Retail _Industrial/Warehouse _L Garage(#of cars 0 )c krrt %il,f
(P doors �i`Lutiou��ly Retnne�d�o�
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: 'R.P L2 Goan c_c-Ae r 6,Dr ( O 116
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Addition/Alteration Application Revised lanuary 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ `1 Sod
2. Source of Heat(circle one): 4 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 _VN'O 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? %,/ PUBLIC _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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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. 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 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: 10 3 Id-1
Addition/Alteration Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Cerrah c_I C N",,_.&\ gk
Mailing Address, C/S/Z: jZ!t?Qft VO `Z)9:k aZ1U3 M la0`14-j- Y 120b b
Cell Phone: 5_r-(3' I Land Line:
Email: h)P9?c,_x cLQ_ Y iJYL—
• Primary Owner(s):
Name(s) 1 -..Ml.
Mailing Address, C/S/Z: VA-464JKY JZQQO
Cell Phone: Land Line:
Email: QC.L& cA_ M . c-O rt^
❑ Check if all work will be performed by property owner onlV
• Contractor(s): (List all additional contractors on the back of this form)
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: S� r$ ) S95`l-aSSd Land Line:
Email: G r'ei►Aq SN%l elr,Ar&"Alnoo cQvv4k
"Workers" Comp documentation must be submitted with this application"
• Architect(sVEngineer(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
• Contractor(s): Workers`'.,Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade: "Ek2c --tc-�+�
Mailing Address, C/S/Z:
Cell Phone:519-33a-7(o-7W Land Line:
Email: uk22.5ArA+bg+� @ 5ra� �, cower
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Na.me(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Addition/Alteration Application Revised January 2021
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1� BUILDING & CODES DEPT. . 11
Reviewed By: �
Date: - \
TOWN OF QUEENSBURY
BUILDING DEPARTMENT
Based on our limited examination,compliance
with our comments shall not be construed as
indicating the plans and specifications are in
full compliance with the Building Codes o
New York State.
309.14-1-22 AST-0727-2021
Chiulli, Gabriel
92 Main St
Detached Garage Alt (post construction)