CC-0035-2024 Office Use Only
i ADDITION/ALTERATION PERMIT Permit#: C-Cr0 03cD — 28
Town ofQ nsbury APPLICATION Permit Fee:$ 2 00 7 I
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#: t0 90
Flood Zone? Y N eviewed
Project Location: 13 VS AO O 1
Tax Map ID#: Subdivision Name
a a. r L NI @�A/ i1
PROJECT INFORMATION: BAN 1 $
1024
Toll*1n
. TYPE: El Residential comm r commercial, Proposed Use: _ EUi �7r.r,_ �',`� �'U„Y
❑ Single-Family El Two-Family ❑ Multi-Family(#of units_) El Townhouse
El Business Office ❑ Retail ❑ Industrial/Warehouse El Garage (#of cars _ )
I '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: LOG 11cjue cc"nVet +a 1911ri VI.
to e + 0.60. c4.M1 c din e. Poo M. f'/J B leg ►l o a E .
Addition/Alteration Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ D 0 0
2. Source of Heat (circle one): ❑ Gas ❑ Oil ❑ Propane ❑ Solar Sher: ElQcic•
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 ❑ NO
SITE INFORMATION:
• Is this a corner lot? ❑ YES I0
• Will the grade be changed as a result of the construction? ❑ YES lI I-Pd'5
• What is the water source? IBLIC ❑ PRIVATE WELL
• What type of wastewater system is on the parcel? ® ER ❑ 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of •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 atrue 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:
SIGNATURE: InGnISV\ PW DATE: d I 1 B a
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Mcr n 5\ ,
Mailing Address, C/S/Z: G 3) D5 faa(42_, 9 (QDeiA l,L my 1 080Li
Cell Phone: ( 5)8 ) 491 - 9,61 fa- Land Line: (5)3 ) 145' t-10 ob _
Email: i'Y)RN�sH p�=)Tcsaa0 Orn L. Cbr).
• Primary Owner(s):
Name(s): &rNniPt-R Pfr.EL .
Mailing Address, C/S/Z: 3c ) N Corn-1r t^No 1jry\s-}iaw-,n 4aN) 12d 95.
Cell Phone: ( 3) S ) 81-1 a —68z`g . Land Line: ( )
Email: larse1,taie1S0 .4, 1• Cart.
Cy-CFieck 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):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: { ) 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:
Cell Phone: ( ) Land Line: ( )
Email:
Addition/Alteration Application •
Revised June 2022