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RC-0426-2023
• (* -tom°. ------ -Office Use Only ) ADDITION/' I'' ► o o P I /II Permit#: ge-e10(® --)O a3 Town ofQuc nsbury "11 ` "LPL I q Permit Fee:$ © • 742 Bay Road,Queensbury,NY 12804 � ` j o�a P:518-761-8256 www.queensbury.net TOWN OF QUEENSBURY Invoice#: Ala r BUILDING & CODES I Flood Zone? Y g Reviewed By: > / Project Location: I W" YoW - a OwkoNSkOv`-1 N 7 Tax Map ID #: '0O p , Ill -.2 `?- Subdivision Name: PROJECT INFORMATION: TYPE: X 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: 1 a Oa 1st floor: 000 St- 2nd floor: 2nd floor: 3rd floor: 3rd floor: Basement(habitable space): Basement (habitable space): Total sq ft: (go Total sq ft: 9b6 S2.c I Scope of work to be done: S Ns_s, UDC IC IA.:T c\I\JLy"1 I tiSoLk ` �,�e ?N IN+ • Addition/Alteration Application Revised June 2022 1 ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ J[� 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 N'NO Explain: 4. Are there any easements on the property? ❑ YES 4( NO SITE INFORMATION: • Is this a corner lot? ❑ YES NO • Will the grade be changed as a result of the construction? ❑ YES INO • What is the water source? PUBLIC ❑ PRIVATE WELL • What type of wastewater system is on the parcel? 'SEWER ❑ PRIVATE SEPTIC DECLARATION: 1. I 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of Queensbury:After 1 year from the initial application date, 100%of the fee is retained. 3.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. I 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. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of occupancy. 6. I 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 C2.0 v 011��, SIGNATURE: f� /1/4,,/—•---- DATE: 0-3- I - 3 Addition/Alteration Application Revised June 2022 I CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL •. Applicant: Name(s): Mkt,lit. fLIA6 Mailing Address, C/S/Z: a9 k 12,t Q� Cell Phone: ( S)(I ) as 9- 01 4a S Land Line: ( ) Email:' ,LA t CVCI 6 y okno, Cc • Primary Owner(s): Name(s): , UQow\ M2 S Mailing Address, C/S/Z: (9 Nr\utx- OLIt Cell Phone: ( Sit ) 30 3 -914( Land Line: ( ) Email: o 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): ./"\,- Ga Contractor Trade: GILL 6\ Mailing Address, C/S/Z: \a\Cn- eiteg )1 t y Cell Phone: ( 5It ) 5 Land Line: ( ) Email: IR QA,cg. -3 U 4 (1 Y,L 00 **Workers' Comp documentation must be submitted with this application** • Architect(s)/Engineer(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: j\ v.t , k' Cell Phone: ( ) Land Line: ( r ) Email: Addition/Alteration Application Revised June 2022 ' .. _. .. • . • •. - - ---. - ,-__ .. ...._ ,. . . .- - --,- , I . ; • , i , , • - ,-- - -- - _ V '1/4?K• C3(\. trYN, ' ' t .. .._ .. __ __ . . _..._ _l___ ,...._•.__. ......._. .....,,_„_.,__...._. :. ., ..1. . ......, ... ..,...,. !. ... ,. . . ... i .... .. . .., I : , , . 1 ; . ; 1 I I ; • ' , . ! 1 • ' E ' - ' ; I 1 ; , : , , ' . . ! 1 ' i J ' , , ! ; ; , i ! 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