2024-0154 . 8- Office Use Only
" ADDITION/ALTERATION PERMIT Permit it 2 24 0151-
Town ofQ nsbury APPLICATION Permit Fee: $ ZLfl--
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Invoice#: 1ly�
Flood Zone? Y (L ' Reviewed
Project Location: ;,111 N1VUVDd Q,tJ S1 � QI,IQ slou,ry
�Tax Map ID #: 5fe . ; — Subdivision Name: &r-e-S-1---pC✓Vk- M He
PROJECT INFORMATION:
TYPE: 2/ Residential ❑ Commercial, Proposed Use:
�ingle Family ❑ Two-Family ❑ Multi-Family (#of units_) ❑ Townhouse
❑ Business Office ❑ Retail ❑ Industrial/Warehouse ❑ 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: 'g CCU-c-- 4 C h(V c-ega:kr
Z - 4 -� � --aL-1 r it (r: �Y �
Y
f MAR 2 7 2024 '
L V y LICANist
Addition/Alteration Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 1 (26 -00
2. Source of Heat (circle one): ❑ 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 ❑ 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? ❑ 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 If, for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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:
PRINT NAME: S- �r d
SIGNATURE: DATE: 31
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): '(ILLI (Air-Gird. , (NtproutmeAt C7c dk-e-ry
Mailing Address, C/S/Z: to Sc.ra,-Izwr P1�Pi
Cell Phone: (51 S ) Land Line: ( Sty ) c—Sq r
Email: ir\o M prt')U2.nn2n1'JJ 0,(Ie(t,' c7 gt ►1 Covu�,
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: 2-t do v r t d
Cell Phone: ( SIB ) 4 01 -tigb 1 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: (-
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: - J �i�ard
Cell Phone: (54?. )`lctu-4oSg Land Line: (St(g )14C SO°t'1
Email:
Addition/Alteration Application Revised June 2022
+ r .,..--- ..
,... ...........-, I 9
^I� MAR 27 2at2°� 4
Home I I r . �.._ _.._. .._.
• Improvement I 1 m -N-. -,,.,;,:„ .. _._.._. . :t.i":\i i • •
So.Glens Falls I 11 1 I 1 -.. , I
10 Saratoga Avenue I i S i t
So.Glens Falls,NY 12803 Galkr / Inc. I I
518 745-5097
NAME Be.745-17 //7//C/r.(' I __—__�_ — — — DATE 3//--- .. 20 - ( —=
' ADDRESS /'/1,47j liod,_.(2 arC.:jC_
CITY at.Pµi‘s� / ? l 2t'.i V
-----._..---.—._ PHONE 3/1'—ya t1 - vv,,ry
SOLD EfrOWNI L ERA INSTRUCTIONS,
TRUCTIONS. I nGa_L-i_cIT
BUILDING & CODES DEPT. 308.14-1-52 2024-0154 '
RevieVted 3yo
Sanders, Betsy
-�_ ._ 21 Briwood Circle
CASH CrituA° —.SO ----•
k 1 aAl•1l. M VISA _
L �-� Roof & ceiling repair
SELLER RETAINS TITLE TO ALL GOODS SOLD HEREUNDER UNTIL FULLY PAID FOR
QUANTITY I DESCRIPTION — --- PRICE I AMOUNT
I _
— 1 -- /.,,A.,,-� r)-t;:-?✓�- (7-•.e r. .1O /.!(1 -I 5- err Z S —� ------�
a CIS. !.gip£ . . .. 1 1
li TOWN Od QUEENSBUF31
- +FR7"N1ENT
r �I /� !' Based on our limited e _
�i- CJ�1.4'if /- '�G'L VIG�!J=_ JAlltkl s)N1t]
t_. /�� //. Indioatinge°1 ��s Thal[not be con trued ae - --
------ j_j— -._/ G_e C"%t -� - .__.. - -- 9 the? .
r /�r fa-conTPlianq I wr hand-s-oeeifloaiians-aye r�----- 1
:��1� u.%f...._._.__�. - - - _ _.._..._._...__Yi \I Yor- • the buildin• g--Codes-o€•-. ......
r— — ------i -- — --- i--—_
Ii' f� '_�1 „('�� ':C'1'�1 l�/C�i�hC _ —/ ——A_-- —SUB TOTAL —_ ! l"/ I Sr _�� _I
l.—_— l —.7?//{4 vc.Gci.r.'—,//�xr}T" J( 4/1'•c //1ci f1!✓• / --�- TAX I �— -
I — Sl7 G/Lf t,lr"/7v�P/t4/ :/�4/ /r4 -c t- ! DELIVERY { —
CO✓z 14G/G0% ( TOTAL i/Of/co,
Due to the custom manufacturing of the product and its restricted use,in the event of any breach on the part of the customer of this agreement,or for any attempted
cancellation after the recission period herein allowed,for any reason whatsoever,the customer shall pay to the Home Improvement Gallery,Inc.a sum of money equal to
seventy-five(75%)percent of the price agreed to be paid,as fixed,liquidated and ascertained damages,and not as a penalty,without further proof of loss or damage. '
Home Improvement Gallery,Inc.shall not be held liable in damages for delays in the performance of this contract due to causes beyond its reasonable control.This
agreement shall be binding upon and inure to the benefit of executors,administrators,heirs,successors,and assigns of the parties hereto.
This contract represents the entire agreement between customer and Home Improvement Gallery,Inc.and no representation or warranty shall be binding upon either
party,unless included herein.
All materials are warranted by the manufacturer.All warranties,either express or implied,as to the materials provided hereunder are
manufacturer's warranties and the Home Improvement Gallery,Inc.makes no warranty as to the materials herein.
DATE .__ _ CUSTOMER
WHITE-CUSTOMER •CANARY-INSTALLATION • PINK-MAIN