RC-0614-2023 L• Office Use Only
• ) ADDITION/ALTERATION PERMIT Permit#: - ' Oc)i4%.- 2 ?
Town ot'Oyeen.sinity APPLICATION Permit Fee:$ 2-1-5
742 Bay Road,Queensbury,NY 12804 -
P:518-761-8256 www.queensbuni.net Invoice#:
Flood Zone? Y Reviewed B
Rzo _h�1�' • F• 1Zcl CI.EVQda .- t2Z2-0
Project Location: I ) 1
Tax Map ID#: . r —r r . . . Subdivision Name: IwT1
PROJECT INFORMATION:
TYPE. Cv7 Residential ❑ Commercial, Proposed Use: d
bd'Single-Family ❑ Two-Family ❑ Multi-Family(#of units ) Tdh' p
TOWN .�.s
❑ Business Office ❑ Retail ❑ Industrial/Warehouse ❑-Garage`.(#__ofr.cars.=21,1:-i•="�.f, )
❑ Other(describe _ -Sc�c ��-� _ )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st-floor.: - 1st floor:
2"d floor: 2nd floor:
3rd floor: 3rd floor:
Basement{habitable.space): _ Basement(habitable space):
Total sq ft: is Total sq ft:
� �
Scope of work to be done: X�`�1�-Gt�'}'"). ( e n 0,1: 'tI-"/0p4"(15/Of)
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
•. Applicant:
Name(s): . ahn i \ c.-1ti n45Oi'�.
Mailing Address, C/S/Z: c.%3 Dan 6(I, I4IA 15bc) F 1I5f 2-A3 -
Cell Phone: (5-l ► ) 16,- (2 O t Land Line: ( ).
Email: I ck1(IS on 76p &j ry 1 r , Can- )
• Primary Owner(s):
Name(s): LcscrctI [41In 0✓�.
Mailing Address, C/S/Z: ' cti 1'y) A .1-1 Ltick 5, C=a 114), iD$.9' ._
Cell Phone:. (5t ) Q LI 0 Land Line: ( )
Email: QC-it-Si-Ed. rlIY14+ L 6-1C,
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) �En ineer(s):
Business Name: H- chi E 5 �10-ekr;
Contact Name(s):' oi"--) rpuj. �Gh�� r) 5
Mailing Address, C/S/Z: /fd`j Zr j (•and' 1Loc \ r -/1t� )C I61
Cell Phone: ( l $ r'-- 0 . t� '� 1223
�. ��/ � �O� Land Lind: ( )
Email:- -b'xt+ch�r,S€ h chio-s erttinQQci ►. Cps
Contact Person for Compliance in regards to this project: Jo 11,-1 Dj C._ 5
Cell Phone: L( a) (a O( -7 Land Line: ( )
Email:J Oh n c�i'c I Cl'n b b''1. to(0 mg.,
Addition/Alteration Application
Revised June 2022
4DDITIONAL°PROJECT.IN FORMATION:
1. Estimated Cost of Construction: $. J l n 00
2. Source of Heat(circle one): ❑ Gas ❑ Oil ❑ Propane 0 Solar Other: tee-A cat c-
Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application
3. Are there any structures not shown on the plot plan? ❑ YES ENO Explain:
4. Are there any easements on the property? ❑ YES 1'N0
SITE INFORMATION: d• Is this a corner lot? ❑ YES NO �/
• Will the grade be changed as a result of the construction? LI YES Lt/ N0
•. What is the water source? ❑ PUBLIC ❑ PRIVATE WELL r a
• What type of wastewater system is on the parcel? ❑ SEWER E 1 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 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: 0 �\ k_l
SIGNATURE: �- l �IVI' +�� DATE:
Revised June 2022
Addition/Alteration Application