RC-0041-2024 E : :a Office Use Only
" �% J ) ADDITION/ALTERATION PERMIT Permit#: Z C'—Or'// "2o t(
Town o Qe�ry APPLICATION
Permit Fee:$ ZZ 0 . 00
742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net , ---------------.__-- Invoice#: `/
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Project Location: 41 �� _ JAN 2 3 2024 1 Jt cOra c i
p TOWN CF -1UEENSt_ RY I
Tax MapID#: 2,9 6 . l' p,I r F -r l'"-• ` U(_1 ':Subdivision Name:
PROJECT INFORMATION:
TYPE: \A Residential El Commercial, Proposed Use:
%Single-Family ❑ Two-Family ❑ Multi-Family(#of units_) ❑ Townhouse
❑ Business Office El Retail ❑ Industrial/Warehouse igpGarage (#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:
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Scope of work to-be done: Ve-p\O Le- Qcyvro \ 1 Sc'tTO i1 in ) KAtc-" C8641e-tq
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Addition/Alteration Application Revised June 2022
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ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 'iv I / 6vO
2. Source of Heat(circle one): 16Gas ❑ 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 0 NO 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? ►l'PUBLIC ❑ PRIVATE WELL
• What type of wastewater system is on the parcel? ❑ SEWER ►2I'RIVATE 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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: CA ut'f.Yte.ri t
SIGNATURE: (��,�r �,.,'"?--F� DATE: i 413123
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): C L f k
Mailing Address, C/S/Z: q{5—(4 rfA fr., 4nvEeskAk1ry
Cell Phone: ( ) 932_ - 7753 3 Land Line: ( )
Email: L.h€,Kexc T k\ . Ct ,�n
• Primary Owner, s): (�
Name(s): 9�d��Q. 0LI`�6.4N 4- Cti�A �J.e. r-A
Mailing Address, C/S/Z:
Cell Phone: ( ) f.� Land Line: ( )
Email:
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):
Contractor Trade:
Mailing Address, C/S/Z: _
Cell Phone: ( ) Land Line: f
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: \N,ce�,f��
Cell Phone: ( ) Land Line: ( )
Email:
Addition/Alteration Application Revised June 2022
X — COf&ADV..2 da.rca-or TOWN OF QUEENSBURY
BUILDING DEPARTMENT trti
;;� � , ror� � OTICEaBased on our limited examination,com liance 37 ��� ctors are required in bedrooms,
- ' with our comments shall not he onstrued as : — t;`'`it bedrooms and ton each floor
• indicating the plans and specifications are in ``°'�i .-; ` a,r• uding cellar tr basement.
full compliance with the Building Codes off « ,� .,`•
New York State. ,„ etPcto. rbon monoxide
"z'0.. . , e4� • ' �3'� < shall be,l terconnnected with
295.19-2-13 RC-0041-2023 F . . ` : .q. s
�, � �, � �• :1•,c up arm vacated on alllevels.
Wiekierak, Chad , -`" Y� �_ C 'e rWq
241 Aviation Rd • - �� � '��� R -
Residential Interior Alterations `''. " { ,':-, •:14 ` t,t
Z°l 9-r 2.4r —12.._-�.' 2, =� I.Lam— J��Rnc..ar1/4,l5 _ �� .„ ;? -a„ ?`
•A �� t TOWN OF O' E .S3UZY
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Scope ofwork to;be done: Ve-p\O- ' tfr \ 1 Sc p°rl in ; k1fG 4rle_t-,r�i
OLys NccS axe �cdeAo� aicvk rke\A l ,,Nse..c�16cti site
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KRAFT PAPER INSULATION
p-Icc v.10A 5 NOTICE MUST BE COVERED BY
R`3 ce'l`irt3 FOAM INSULATION MUST BE NON-COMBUSTIBLE BARRIER
COVERED BY A15MINUIE
THERMAL BARRIER
Addition/Alteration Application Revised June 2022