CC-0517-2023 6
g- ) Office Use Only
N _ ADDITION/ALTERATION PERMIT Permit#: CC —OF)t2-- 213 2
APPLICATION
Town of Quccnsbu i� Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-7614256 www.queensburv.net Invoice if: 6e 0
Flood Zone? Y ili Reviewed By:MC'
Project Location: 21<P ler Qt4eNthAli 218D
it
,, CV PIQUk
Tax Map ID#: 3��' l �'�1 -"� Subdivision Name:
PROJECT INFORMATION: 11 409 '``--.
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CCU 4 `, . CiW�11[Gf Vl�� AOr
TYPE: 0 Residential Com e ci i, posed Use: I
'29: /'
El Single-Family 0 Two-Family 0 Multi=Fa ily(#of units_J 0 Townhouse
❑ Business Office H Retail 0 Industrial/Warehouse 0 Garage(#of cars )
❑Other(describe )
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2nd floor: 2nd floor.
3'd floor: 3rd floor:
Basement(habitable space): Basement(habitable space):
Total sq ft: Total sq ft: 1,6 0 Q
Vert 1-1-#`1SC
Scope of work to be done: I-WPFi4-41 O P 4"t'6-' ti r fr'r Le
(_p to h 4 \A-4 k s vireo:. 4 6 vt,�[P,�".$ .1Q-Q '�&C2 -�OVIL
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W`. (L.�P fig):;.,VC Y `1 I'. 0, '_i . r� L C,l l r-� i1, t Cc (A) E-! "
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h-� Lac( S I Ire pa,�,l VJ o Lts, 2e p(cci ,,I roO
Addition/Alteration Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$ I ) rj
2. Source of Heat(circle one): dGas 0 Oil 0 Propane 0 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:
there anyeasements on the property? ❑YES '(NO o.� ASIt?1141 "l0 I ^I
4. Areh ufiir
SITE INFORMATION: rfiS [tits < <'
• Is this a corner lot? ❑YES NO to` J
• Will the grade be changed as a result of the construction? 0 YES NENO
• What is the water source? 7 PUBLIC ❑ PRIVATE ELL
• 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 l/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: •
7 I
DATE: I
SIGNATURE:
Revised June 2022
Addition/Alteration Application
—mom
A
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A licant: I i
Name(s): et,IV► V- I>>
Mailing Address,C/S/Z: 115.26 I-1 01 s gtt-a- 203c ..C .r es 1�c 5
Cell Phone: ( '-3 ) z3 - /AI I Land Line: ( 3 ) 1)8 2--77!3
Email: fVVI (a mico(Awn on 1,1 ove--t)01ACcYu ter' LOV
• Primary wner(s):
Name(s): 12A1A i AV -W(4S( [-to
Mailing Address,C/S/Z: t`1,-(1 pJ 4%\6I / i' 'CM( tics 1 'L `ei It!Cell Phone: (1014- ) (elf - 00 Land Line: ( ) n (61
Email: YVIA.rkS r[ (J4 .f-jSOh(a t( c &owl
0 Check if all work will be performed by property owner oh
• Contractor(s):(List all additional contractors on the back of this form)
Contact Name(s): rni 14& eft 11115 1 To 12
Phi . , Lk .
Contractor Trade: -P\cF 'irC k G ((Al
Mailing Address,C/S/Z: PO ( .c*X 2-i OGI Eziot, s -6A19 r fj /LrD S
Cell Phone: ( 51$ ) P' 4 —072$o Land Line: ( ) V114
Email: 0;4\4- Ot. 12o01 @ \J/- k00. £ W
**Workers' Comp documentation must be submitted with this application**
• Architect(s)/Enaineer(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: S7-1l
Cell Phone: ( , ) ' 3 -- ( 1 Land Line: (`Z 22 ) 8 ,2 — 1713
Email: k5 ir1 15v1)C& 1r-trliV lr vt Veen 02 (6 2r f CO 941
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Addition/Alteration Application Revised June 2022
R I
• Contractor(s):Workers'Comp documentation must be submitted with this application
Contractor Name(s): Ca)/0 bti(, I 1A/IM b (n/ 4, I11/t6 • .
Contractor Trade: -t, L h I lit,I '4j l/ 1l C '1;+?O(A i
Mailing Address,C/S/Z: tYV ' �tL( , ( \t cc IC-UR� j o y t 2 o)-
Cell Phone: Laid Line: (si g ) i s — (�S 60 J
Email:
• Contractor(s):Workers'Comp documentation must be submitted with this application
Contractor Name(s): (-:10 j._
Contractor Trade: c- c'!�i t C .. (�v j-I t G� - Y
Mailing Address,C/S/Z: '2? c { ‘ft./ 0, ; O.t- �,�; JE.,�rp •
HCl€-
Cell Phone: land Lane: E.J- ( � 4 —• d 7i
� G
Email:
• Contractor(s):Workers'Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone: Land Line:
Email:
•
• Contractor(s):Workers'Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone: Land Line:
• Contractor(s) Workers'Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address,C/S/Z:
Cell Phone: Land Line:
Email:
Wad Juno 2022
AddttionNteralon Appliation
C" : r''+t
• FILE COPY • r--:\ TOWN OF QUEENSBURY
BUILDING DEPARTMENT
Based on our limited examination,compliance
with our comments shall not be construed as
indicating the plans and specifications are in
• full compliance With the Building Codes of
New York State. -
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