RC-000747-2017 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development Building&Codes (518) 761-8256
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CERTIFICATE OF COMPLIANCE
Permit Number: RC-000747-2017 Date Issued: Monday, July 2, 2018
This is to certify that work requested to be done as shown by Permit Number RC-000747-2017
has been completed.
Tax Map Number: 295.18-1-29
Location: 11 WHITE PINE RD
Owner: Heidi Robak, Walter Robak
Applicant: Walter Robak
This structure may be occupied as a: Residential Interior Alterations 120 s.f
(converting existing laundry room to bathroom) By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the
property owner of the responsibility for compliance with Site Plan,
Variance, or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building& Codes (518)761-8256
BUILDING PERMIT
Permit Number: RC-000747-2017
Tax Map No: 295.18-1-29
Permission is hereby granted to: Heidi Robak
For property located at: 11 WHITE PINE RD
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Type of Construction
Owner Name: Heidi Robak Single Family-Alteration $2,500.00
Owner Address: 11 WHITE PINE RD Total Value $2,500.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Walter Robak
11 White Pine RD
Queensbury,NY 12804
Plans&Specifications
Residential Interior Alterations 120 s.f.
(converting existing laundry room to bathroom)
$60.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,December 13,2018
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensb beforjthee 'ration date.)Dated at the Town o Queens �We ecember 13,2017
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
A
Office Use only
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ADDITION/ALTS
Permit
#: r C- 2-('t7
APPLICA I IE C E 0 TPE ce: $ ,'DC7. 60
Town ofQueensbury
742 Bay Road,Queensbury,NY 12804 � � � l�jn j �q�'o
DECP: 518-761-8256 www.gueensbury.net G
C✓ r'% f cT 0 QUEENSBURY
Project Location: l INQ&CODES
Tax Map ID#: `� 1 /fl- / " Subdivision Name: �0A/e
CONTACT INFORMATION:
• Applicant:
Name(s): 4,119,e 7''," /fU &
Mailing Address, C/S/Z: // l.��J �' ,¢'=��� /�� d `'�"'5,.AL`y
Cell Phone: e SSE' 'K 3' S Land Line:
Email:
Primary Owner(s):
Name(s): �✓ � ��r fit.`�°�` ,f�� �,
Mailing Address, C/S/Z: s'�� c
Cell Phone: ( Ste. c Land Line:
Email: SA-7c
• Contractor(s):
Business Name:
Contact Name(s): Gee' r>' �C'd�' .-
Mailing Address, C/S/Z:
Cell Phone: ( S'9'<-+ c Land Line:
Email: S' 'f- r c'
• Architect(s)/Engineer(s):
Business Name: //0w c
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Building & Code Compliance: `% AlC"
Cell Phone: _� ) S.�- c Land Line:
Email:
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial Residential
WORK CLASS:
Single-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: eki �x1si»+y L�,".Jf.J .f'
3rd floor: 3rd floor: —� �' �3s7ti �Qr^
41h floor: 4th floor:
A10 c <wAE
Total square feet: Total square feet: E' •`sr' Sf -4
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ e Ste'
2. If Commercial project, what is the proposed use:
3. Source of Heat (circle one):(' Gas Oil Propane Solar Other
Fireplaces need a separate Fuel Burning Appliances &Chimney Application
4. Are there any structures not shown on the plot plan? YES NO Explain:
5. Are there any easements on the property? YES NO
6. SITE INFORMATION:
a. What is the dimensions or acreage of theparcel?
b. Is this a corner lot? YES
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? P BL PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? 'FC
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017
DECLARATION:
1. 1 acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be
completed within a 12 month period.
2. If thework is not completed by the 1 year expiration date the permit may be renewed, subject to
fees and department approval.
3. 1 certify that the application, plans and supporting materials are a true and 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.
4. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
5. 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:
SIGNATURE: DATE: _r AZ/
-/-7
Town of Queensbury Building&Code Enforcement Addition/Alteration Application Revised February 2017