CC-0551-2022 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: CC. ""Or."- 1- 10 2 -
• Town ofQ APPLICATION Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: V1
Flood Zone? Y Reviewed By: M
Project Location: I' `/9 Sk("" O J• % zJ 6-1 / 1 'r
Tax Map ID#: � ) � Subdivision Name:
PROJECT INFORMATION:
TYPE: ❑ Residential 15 Commercial, Proposed Use:
❑ Single-Family ❑ Two-Family El Multi-Family(#of units_) ❑ Townhouse
❑ Business Office g Retail ❑ Industrial/Warehouse El 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: R-e— 0 F°"C-- ��C( ` ;a-rs- k .)G I,_ (1.04
5
Addition/Alteration Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
•
1. Estimated Cost of Construction: $ 66Z5'
2. Source of Heat (circle one): 1"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 IrNO Explain:
4. Are there any easements on the property? ❑ YES - NO
SITE INFORMATION:
• Is this a corner lot? 0 YES I NO
• Will the grade be changed as a result of the construction? ❑ YES 'NO
• What is the water source? IUBLIC ❑ 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 age e to the above:
PRINT NAME:
SIGNATURE: DATE: 5
Addition/Alteration Application Revised June 2022
® CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Name(s):
Mailing Address, C/S/Z: UI
Cell Phone: ( "" ) `a-6G 7 6 G/ Land Line: ( )
Email: o-,c -'.eS c• d r� cy e. , Lcaiw
• Primal* Owners : f /
Name(s): �o�« �t �4,d !G-P (��. (a
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( )
Email:
El 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): 6-4' L�C--
Contractor Trade: 4-e-t-e tea,
Mailing Address, C/S/Z:
Cell Phone: (c' ) 760/ Land Line: ( )
Email:
**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: I. r(1- -5 , `�
Cell Phone: ( r) --710 Land Line: ( )
Email: 4v c •es AV .� . ,1.
Addition/Alteration Application Revised June 2022