2024-0249 411.0 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: 2o2 - 6219
Town ofQuccnsb ry APPLICATION Permit Fee:$ 220
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#
Flood Zone? Y N Reviewed By:
Project Location: 3 7Y .4/ v7Lute_ /FoeLtie, 6giov
Tax Map ID#: 2& j . /o 1 - Subdivision Name:
PROJECT INFORMATION: MAY 2 2 2024
d
TOWN OF QUEENSBURY
TYPE: Residential ElCommercial, Proposed Use: BUILDING&CODES
'Single-Family ❑ Two-Family ❑ Multi-Family (#of units_) ❑ Townhouse
El Business Office El Retail ❑ Industrial/Warehouse ❑ Garage (#of cars
El Other(describe
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor: /O. 1441
2nd floor: rg_IE f o r:
3rd floor: .=flour:'
Basement(habitable space): Basement (habitable space):
Total sq ft: Total sq ft:
Scope of work to be done: 4 deed ,e// �y! yeti j)tjr rcrckde-)
a cJ L,01, goio7� S vL iL..Sfwel e erra di7J V ii iu/ F�IOC��'o7� rr�iR c, -eiVef44i My
reftove ad t I &tsfi e-coe3 ter'") S '� a a/c„ �ir7 6i /d � /� coJe
(5pif / kee-y455) _x,S'pr 40n1 c,i/fD/e ie elAcetz�� tt r� Zee h� /5 , k>g o,/,
r
ai,iy % e % ,11 ef 4reve°; 1e -kw/A_ %c�ri J 4 aced rdek , Wc✓fi y vt c �
•
me icJ M , ,erca/a_ Lo th r ply,
Addition/Alteration Application Revised June 2022
,14
ADDITIONAL PROJECT INFORMATION: G�
1. Estimated Cost of Construction: $ /®/ 9$/
2. Source of Heat (circle one): ❑ Gas ❑ Oil �'1 Propane ❑ Solar El Other:
Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application
3. Are there any structures not shown on the plot plan? ❑ YES YI NO Explain:
4. Are there any easements on the property? ❑ YES 0 NO •
SITE INFORMATION:
• Is this a corner lot? ❑ YES NO
• Will the grade be changed as a result of the construction? ❑ YES 0 NO
• 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 If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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:
�
ailPRINT
NAME:
SIGNATURE` � DATE: 372----2 L V
Addition/Alteration Application Revised June 2022
ti
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
•Name(A:- I / 6216‘1647,- �LC -'- Z&e-C/L aeue/ei-nd
Mailing Address, C/S/Z: 7_0 (/y Afc 4( Mui cn "orn' 12-63�°
Cell Phone: (57w ) 8'/1`5730 Land Line:
Email: redeye/arid Ac&claoe•conn
• Primary Owner(s): 0
Name(s): Ir�/c Ayld 6,47 Sec.�/G
Mailing Address, C/S/Z: 2 Couvi 4,7 ae a Qv C'ry /07
Cell Phone: ( ) 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): d C(Aih4 - R r) fnIchl-1)
Contractor Trade: 0, gekei effidsvA G1-6
Mailing Address, C/S/Z: 10 foul !j( E-(� l Af(s /1/Y
Cell Phone: ( ) se/i'(73w Land Line: ( )
Email: rcleve zd/(e -arm
**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
MAPNO
N 1. Boundary inforinadon shown hereon rta.5coinpilecifr(im map reference 1,and di7 actual field survey conducted oj7 March 8 2022
topographic data collertedon.%-TtembertZ 2022.
2 North Orientation and bearing&.9eper map reference L
A Warren County taxparxI289.lal-46.
4, there may N,
other underground utilities,the existent of which are unknown. Size andltvifion ofallundeiground Wilities must he verified
L?ythc,,ipl?i-ol7rii7teitithofitiLs. T]7eUndcTgrotin4iFaciliticsPr-otcctivcOrgini4itionnizistLx,,notificdpric)rtvcontfuctingtcwt
lx,nngs,exca cation and construction.
.5. This survey waspreparai without the beaefit ofan Up to dalvalistract of title.
6 Elevations relative to the North An7er4ain Ilerfical Datum of1988
7 Reproduction or copying,ofthis document inqv bea violation ofcopytightlaw unlas!.5 pemilssion oftbe audiorandl or
rapj,rIght holder is obtained
S. A copy of this document withonta proper application of the surveyors embossvd sealshould be assumed to be an unauthorized
copy.
DEEDREFERENCE
1. Conveyance to Fr
ancis and Cindy R..9teciuk,Trustees of the rr,7j7ci,51.,1,7tecittkRevocable Living Trust dated June 25
\ 2(120,fiv dead dated July 2y 2022,fi7cd in thtz iNarsen C:vunty C/erks Offt'ce on Autnrst 2,2022 in Baok 61a87of Ueeds at page 29Y
Z
o
MAPRFFFXFNCE5
round �Q L Map entitled Xbp ofAiundcoy.5,orvey Lands Now or Fonnerly of The Betty A.5padaro Living Trust,,prepared by DolrTh
1 and,5urveying,TTLC elated March 18 202a.
Lands Now or Formerly of
1—RV P �d E 0 W
Gary
Bdlert, Trust on lme
Book 5321 Page 115
MAY 2 2 2024
289.10-1-53 l:roe
ti
TOWN OF QUEENSBURY
1.2 Area=0.0_±Acrv,1, B*nk BUILDING&CODES
k X/ 131-k 7.1,Vi
�,the y AlW*,v Fund v/67).1 Vir-
lin, /A X 405. 05.5
OHW
OHW— OHW Lands Now or Formerly of
Harvey D. Irilson
0
Man— 404.2 anent 40&S Book 669 Page 897
11 1 -1-1
Elixir is "
F,
289.10-1-45 !,j
40,4'.4
77,ho 405,7/
z x 411.5 Z
Lands Now or Formerly of
Paul S Zemanek, III
Q_AVLAKE
Glen Lake 399, Book 1287 Page 54
411, N
289.10-1-52.1 & 52.2
MOT 10u,ALF
9 1 9.3,
R"fr d
DRAFTER UNAUTHORIZED ER-2.OR ADDITION'TO THISALET graphic andHoundarySurvey
DATE VIOLATION 0 SECTION 7209
KRISTIN M. DARRAH REVISIONS RECORD/DESCRIPTION Map of a Topographic
050803 DOCUMENT IS A
...... SUBDIVISION 2 OF THE NEW PORK Lands A1oTv arl0rinei y of
"k
,11, illIq STATE EDUCATION LAW.
V-1ion 0 2022 Francjsj and Cindy R. Steciuk
4,_;
Er 41_,�, oFN D.IT.h Lmd Surveying, PLLC Trustees
MAMRa APPI?0VED KA,1D JOWN01,QUEENSHURY WARREW COUNTY NEW YORK
DRA1717?., .44WB
CHECKED.-A44T A5. Darrah Land Surveying,PLLC 22249-1
IIRQJ�NO.� 22249
AID$ Voice:(518)798-4692 5HFET I OF I
"ONI,YBO)Nr)ARYSt7RVEYMAI',wiiii,riii,,S(.IRVF,YORSr,MBOSSr,D SCALE: P=30' or(918)6,54-94,76
II,1;F'1,1K1, '1 Nl��IIIU 1,AND .,OR RE-I Ul)PI ES OF I H F Sk IKVFYl Ms F P1?0JN0 2124 9
)PINION. DATE:91712022