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CC-0606-2023 r a -_ Office Use Only ADDITION ALTERATION PERMIT , ` =-r� � Permit#: CC, ©61)k-.).— 20 2.-5 Town ofQe s ury APPLICATION Permit Fee:$ 14\A 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Invoice#: Flood Zone? Y N Reviewed :y: L / Project Location: Gurney Lane Recreation Center- Hansen Center Tax Map ID#: 288.-1-47 Subdivision Name: NA PROJECT INFORMATION: TYPE: ❑ Residential 121 Commercial, Proposed Use: Recreation Center ❑ Single-Family ❑ Two-Family ❑ Multi-Family(#of units_) ❑ Townhouse El Business Office ❑ Retail ❑ Industrial/Warehouse ❑ Garage (#of cars ) ❑ Other(describe ) ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE: 1st floor: 484 SF 1st floor: 2nd floor: 2nd floor: 3rd floor: 3rd floor: Basement(habitable space): Basement (habitable space): Total sq ft: 484 SF Total sq ft: Scope of work to be done: Addition to the Hansen Center at the Gurney Lane Recreation Center l 1 VIE r1:: vi1 1I u SEP t -u 1 Isar 1 ` ('MIN OF Q�UEENSr,r.li'Y i L BUILDING & CO stti �.-J Addition/Alteration Application Revised June 2022 ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ 50,000 2. Source of Heat(circle one): ❑ Gas ❑ Oil ❑ Propane ❑ Solar Zither: Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application 3. Are there any structures not shown on the plot plan? El YES ❑ NO Explain: 4. Are there any easements on the property? ❑ YES ❑ NO SITE INFORMATION: • Is this a corner lot? El YES 2 NO • Will the grade be changed as a result of the construction? ❑ YES 2 NO • What is the water source? 2 PUBLIC El PRIVATE WELL • What type of wastewater system is on the parcel? ❑ SEWER 2 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of Queensbury.After 1 year from the initial application date, 100%of the fee is retained. 3.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: Ethan P '/1 -Ar -< �'for the Applicant SIGNATURE: DATE: 20 Sept 2023 Addition/Alteration Application Revised June 2022 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): Town of Queensbury-Recreation Department Mailing Address, C/S/Z: 742 Bay Road, Queensbury NY 12804 Cell Phone: ( ) Land Line: ( 518 )761-8200 Email:stevel@queensbury.net • Primary Owner(s): Name(s): Town of Queensbury-Recreation Department Mailing Address, C/S/Z: 742 Bay Road, Queensbury NY 12804 Cell Phone: ( ) Land Line: (518 )761-8200 Email: stevelna.queensbury.net ❑ 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: Rucinski Hall Architecture Contact Name(s): Ethan P. Hall Mailing Address, C/S/Z: 134 Dix Ave, Glens Falls NY 12801 Cell Phone: (518 )260-2888 Land Line: ( 518 )741-0268 Email: ephall@rha-pc.com Contact Person for Compliance in regards to this project: Ethan P. Hall Cell Phone: ( 518 )260-2888 Land Line: (518 )741-0268 Email:ephall@rha-pc.com Addition/Alteration Application Revised June 2022