applications _. b 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-0792-2019
Tax Map No: 288.16-1-29
Permission is hereby granted to: Ridgewood Homes
For property located at: 138 EQUINOX 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
Tyne of Construction
Owner Name: William Bergman Single Family-Alteration $30,000.00
Owner Address: 138 EQUINOX RD Total Value $30,000.00
Lake George,NY 12845
Contractor or Builder's Name/Address Electrical Inspection Agency
Ridgewood Homes
14 OWEN AVE
Queensbury,NY 12804
Plans&Specifications
Basement Renovation 1344 s.f.
$403.20 PERMIT FEE PAID-THIS PERMIT EXPIRES: Monday,December 21,2020
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town of Queensbury; /J Friday,December 20,2019
Ea,�j SIGNED BY: ld44:� for the Town of Queensbury.
Director of Building&Code Enforcement
Office Use Only
-ADD ITION/A LTERAT-ION-PERMIT Permit#:
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To of Queensbury � J�}
742 Bay Road,Queensbury,NY 12804 I ' I� I
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P:518- c761-8256. www.gueensbury.net �r1 DEC i z
Project Location: f 39 tau i Al�`�� � ,OF ! �c1V�BURY
DIN �' rOES
Tax Map ID #: 2 & / Z�' Subdivision Name:
CONTACT INFORMATION:
• Applicant:
Name(s):
Mailing Address, C/S/Z: _ 1 �l'�e,� �l.� .,,�
Cell Phone: 5ig )_ �fvl�- �w Land Line: � )
Email: r i J Q P eJ . �[> y11a cA MA-t L af�
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: fG�Iws Y�L,jI�
Cell Phone: ('3jP, Land Line: � )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contact Name(s): �P��r�n t I'� i L fR%,�Ewo—ci
Contractor Trade: _ Claet_^4_7i!
Mailing Address, C/S/Z: Elu ,,&Z aL EEV_$bL,---uY 1 Z 'ep-v
Cell Phone: - ( S[A' I >1-476 Land Line:
Email: t L C& &>e%,
"List all a ditional contractors on Ae ba of this form
• Arch itect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line: ( )
Email:
d e
Contact Person for Building & Code Compliance: V1A,►
Cell Phone: a i8 q&`7 Land Line: � )
Email:_ rI Age_i ocx)> konm,3 i-�A 'am
Addition Alteration Application Revised February(/
PP rY
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•-__-Contractor(s): Workers.'-.Comp.documentation.must be.-submitted-with this_applicati _n_-_-
Contact 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
Contact 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
Contact 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
Contact 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
Contact 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
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line: �)
Email:
Addition/Alteration Application Revised February 2019
PROJECT I114FORMATION:
TYPE: Commercial i Residential .
WORK CLASS:
t' 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. i1 V41
1st floor: 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total square feet: Total square feet: , I
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ ' fO Cx��
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 the arcel?
b. Is this a corner lot? YES
c. Will the grade be changed as a res t of the construction? YES NO
d. What is the water source? BLIC PRIVATE WELL
e. : Is the parcel on SEWER or a PRIVATE SEPTIC system? �'"t v'►� e '1C�
Addition/Alteration Application Revised February 2019
f `
DEC RATION:
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. Ifthework 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], 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.
have read and agree to the above:
i
PRINT NAME: ,►,�► C )
SIGNATURE: UDATE: z It f
Addition/Alteration Application Revised February 2019
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FUEL BURNING APPLIANCE & office use only
CHIMNEY APPLICATION Permit#: - b `1,2 74I�
Permit Fee:$ I2.�
ToWn of Quecrisbury
Invoice:#:
742 Bay Road, Queensbury, NY 12804
P:518-761-8256 www.gueensbury.net
Project Location: 13S C vino di V i� Tax Map ID #:
IV
Room of Install: )5 M i rm M Planned Install Date: Aa ZOZ-0
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION: E C E 0 W E
• Applicant: �1 ( JAN !0 2020
Name(s): ,��7iI� (�r✓IJ)�r i
Mailing Address, C/S/Z: 114 Qtyi:nk) � i Ii i R.
rx.) 1Jvo\
i�l nl i'al;�ilry �e �:��or,77,;
Cell Phone: ( 518 ) 36/- V76 Land Line:
Email: t- r)�tAaall 4 1.c7VV- c LN G iv.A-L . Cc
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( 51L ) Land Line: _( )
Email:
❑ Check if all work will be performed by homeowner only
• Installer Builder: `Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade: v tLJZV
Mailing Address, C/S/Z:
Cell Phone:_( 5'It5 Land Line: _( )
Email:
Contact Person for Building & Code Compliance: Vey,v% (: vL, If;,- L
Cell Phone: _( eil B ) 1,1_q(,, Land Line: _( )
Email: r ,
Fuel Burning Appliance&Chimney Application Revised February 201
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _ Fireplace Insert Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built**
(**Manufacturer's name: Model #: )
SOURCE OF HEAT:
_Wood _Coal _ Pellet _XGas
CHIMNEY INFORMATION:
Masonry (require plans to be submitted):
block brick stone
IL Flue:
_tile _steel _size, in inches
_Material*:
double-wall _triple-wall_insulated
(*Manufacturer's name: Model #: )
1. Two inspections are required. A rough-in inspection, prior to installation and a final inspection, after
installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces &chimneys require plans to be submitted.
4. Twenty-four(24) hour notification is required for inspections.
5. Workers' Comp insurance information is required with this application.
Declaration:Construction/installation must conform to NYS Fire Prevention & Building Code and/or manufacturer
requirements. The applicant or owner agrees to comply with all applicable laws,ordinances, regulations and all
conditions that are part of these requirements and also will allow the inspector to enter the premises to perform the
required inspections.
I have read and agree to the above:
PRINT NAME: 9;:a cr /
4r)11;�a
SIGNATURE: DATE: 1
Fuel Burning Appliance&Chimney Application Revised February 2019
-7
2019
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150' APPARENT PROPERTY LINE FROM REFERENCE4Jjl� �I. � /`�u�.�.3t� 'r
SUBDIVISION MAP & WARREN COIIN'1'Y G ,E
t$elatioli Home ow( se.
TOWN O �1E_ SBURY Q
Please assure you are familiarwith the
f'"AZDiG r ES DEFT. Pool Enclosure requirements specific to
I'-iviewed D' Your pool. We will be happy to explain
Gate: LZ i what Requirements yoLDAjLjqrdMo
meet perAppendi� f (��
p New York State Resicrenfi�al��odeF
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EXISTING 1^UVV SYSTEM'
15 REPUTED TO BE
IN THE FRONT YARD
TOWN OF QUE NSBURY
BUILDING DE P RTMENT }
Based on our limited exarpalion,compliance _ ' 0
with our Lrommenis shall I1ot be conshed as NOS,
indloating the plans and ecifcat ons are in
.............
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full cam Hance with the uilding Codes of " "' 51TE PLAN OF 5UILDING ADDITIONS,
1
NoWYO $fate. ,=> POOL HOUSE,POOL B PAMO ARE
-� -r-� SIl1JATED PER MAP FtEFERENGE- 2,
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GRAVELESS CHAMBERS " - CONCRETE SEPTIC -
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