CC-0699-2023 •
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Office Use Only
ADDITION/ALTERATION PERMIT Permit#: CC.-0 -`'1'1 - 20 2.�
Town ofQ�b , APPLICATION Permit Fee:$ '(
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#:
Flood Zone? Y N Reviewed By:
Project Location: 2 ooc\Jc\ --?-..c:\ Q_.e-e SV)C,I, k\l Va-S014
Tax Map ID#: Z'(o.i "(_ 1 1L1 .Z Subdivision Name: ` `er' ..n GO(V �,M
PROJECT INFORMATION: ,
dCT31
TYPE: ❑ Residential 7-0 �-.cmmerl7Prog
Use:
El Single-Family El Two-Family MuL€ifFg y(#o units_) ❑ Townhouse
❑ Business Office ❑ Retail ❑ Industrial/Warehouse El Garage (#of cars )
Other(describe Ne›-- A \•J; iv� •
) •
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: Ite.\O c c €. Z Scpc-\ A��e--c. o,4\e� CC-GA&e Z L3 \ls
0N- e-. -e e t\c. . oc cv.r\ % ..\--ccs, e- Co c--- ice c-oc-- y‘ -•1\ ,kk ,
Co+v\exN No QV VA . .cac:%Scsnn -Nco___ a\e-_-\ -
Addition/Alteration Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
0
1. Estimated Cost of Construction: $ ‘q 1�OO Q'
2. Source of Heat (circle one)OD, ❑ 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 tcll NO Explain:
4. Are there any easements on the property? ❑ YES NO
SITE INFORMATION:
• Is this a corner lot? ❑ YES 0 NO
• Will the grade be changed as a result of the construction? ❑ YES NO
• What is the water source? ❑ PUBLI ❑ 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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: U "
SIGNATURE: DATE: 1O 1 30 t Z_
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: l
Name(s): Sc_�nc��e.l���cer .1xeve.�tcl��S ,�.�-
Mailing Address, C/S/Z: '1%O% CCce_e .c•c\ce. Cyr -S\O t`il2e10o N `.� 1 `�
Cell Phone: (Colt- ) SS'A -56 1U12 . Land Line: (°SZ ) 3aS
Email: w \\b Sc-Voe.c\C-c\Aer Ce\on/ok#to n5 •c.c.,,M
• Primary Owners):
Name(s): L6o plc I,...L.C-
Mailing Address, C/S/Z: QCti. c 212cl So��r.NiakVe-\x 1(a R Z_
Cell Phone: ( ) Land Line: (Sty ) 1°3- S(SSCf,
Email: %zww. ?e .sc Se.oc \LA nc1. r�M.
❑ 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): Sc�o �-c\s- �1Ze.\CDV0,160(\e mac_
Contractor Trade: C.od\S v coo
Mailing Address, C/S/Z: "VtOg C_-r-Ate-lx. ,cL e_ C c IV)
Cell Phone: (tort.- ) 5Sc-1.- <g jR Z. Land Line: ("ItcZ.) 34S--LW: 7
Email: vJ:\kb Sc e .ce.43.e.rceinovc c,(\ •COM.
**Workers' Comp documentation must be submitted with this application**
• Architect(s)/Engineer(s): \
Business Name: �oSe €. Nt' �'tcLc-\
Contact Name(s): She �� S2a.Z
Mailing Address, C/S/Z: %00\ a v cc kt 400 V,r. ►eh� i ZZ\SI
Cell Phone: (-103 ) 2&ct - ' CS0C3 Land Line: (103 ) 4 ZC. - v5--"i
Email: Sc"..7-‘Z0 .cow
Contact Person for Compliance in regards to this project:
Cell Phone: (GO.- - Land Line: (qS2 ) 34S- 2400
Email: w:\fib c ScLoe_A•Cre1r.kes c, - ca.'S. co V
Addition/Alteration Application Revised June 2022
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): c„04.A.?o,iN1/41
Contractor Trade: SPe-,rn1.(\¢,r f c-e_
Mailing Address, C/S/Z: ?os%c �� 5 ;\ \�pc,�Y n� 1-LLos--
Cell Phone: S%$ 2512 Land Line:
Email: onGcr A.1/4A5
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): MC Oc C�Jee.�s�lJ�ry
Contractor Trade: rarnc;.c N
Mailing Address, C/S/Z: -I C_W.99e--DQ
Cell Phone: Land Line: S 1'6 41S'\3Z\
Email: AC;C� nnC�.o �eec�sbo��.ter,
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): 0.=,a\s 1ol *e,?c C-csp
Contractor Trade: 2e,,,,ou o, ion.
Mailing Address, C/S/Z: '4(O \�..i�.r� �� Z.c), "4,\c o c.. N•I 1094,\
Cell Phone: c g y-/1 - Land Line:
Email: Ceoby c \€k 4' o \c N4 . com
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): Qt�je. \ae-yor c). CAce. ��c) SC_C.A.W"'NflLLC_
Contractor Trade: Spr',A1-..Ness
Mailing Address, C/S/Z: `c53\ ts1Y -!off 2.1 C 1�\\S\sC,n 4\.y 1 Zs0-Zd
Cell Phone:Sig St;(,-cD°t\ Land Line:
E. ►% 0ooVe.a4Q�o�e�c��;o�.�M
• 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 June 2022
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1 ° CY E 11 V ED
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1 NOV 2 1 2023 .
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COMMONWEAL:1'R ELECTRICAL,INSPECTION SERVICE%INC.
Main Office 176 Doe Run Road-Manhelin,PA.175411 , • • • ' ..741,:s
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OF • rvi QIN!ci PAL.CERTIFICATE - ELECTRICAL,APPROVAL • • • .4,4
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Permit No, 6.99- 20-----7-2-' Ceft- N2 50 19. 2 Cut-i.iii:trd No :
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.MC C°Nit i0ir? lollowinpEeverned the issuance of this certificate,and any ecrtifienie previously issued is
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• This certificate only cnvers the electrical equipm'ent and installation conditiuns 4i$ of date. Upon the l
introduction of adthlienal equipment or alterations;'application hall be promptly'made for inspection.
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..:ii.s.. inspectors till the, Co»tpail shall have the privilege of making inspections at any time, and if its ! ; . .! •:;:.,ail
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v!,11,,, • . i rules are violatti<I,'!hc Compam,/shall have the right to r ke ithis cerrifictitc. •kt,..
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Date /re-A°-f2-•3 INSPECTOR„ ....a//W--'"41.44'1,"°--(-'tr"-- • i
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Member IN.F.P.A.,I.A.F.J. 1 • • --•;.:s;
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