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applications Office Use Only ADDITION/ALTERATION PERMIT Permit#: 1g-C 'D ‘C7 /—7o C APPLICA'T �' $ �S� 00 Town of Queensbury ! � PY11 Fee 742 Bay Road,Queensbury,NY 12804 j # , d D P:518-761-8256 www.queensbury.net f ; AUG 2 3 20 Oln i_ o1 ¢ `t 1 q vy1 Project Location:_470 West Mountain Road TOWN OF QUEEt'JS 3 iiY Tax Map ID#: _301.17-3-70 s6dBiatus CONTACT INFORMATION: • Applicant: Name(s): David Howard Mailing Address, C/S/Z: 470 West Mountain Road, Queensbury NY 12804 Cell Phone:_(518)361-3243 Land Line: _(518)792-0222 Email: • Primary Owner(s): Name(s): David&Diane Howard Mailing Address, C/S/Z: 470 West Mountain Road, Queensbury NY 12804 Cell Phone:_(518)361-3243 Land Line: _(518)792-0222• Email: x Check if all work will be performed by homeowner only • Contractor(s): Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: Cell Phone:_( ) Land Line: _( ) Email: **List all additional contractors on the back of this form • Architect(s)/Engineer(s): Business Name: Rucinski Hall Architecture Contact Name(s):_Ethan Hall Mailing Address, C/S/Z: 134 Dix Ave, Glens Falls NY 12804 Cell Phone:_(518)260-2888 Land Line: _(518)741-0268 Email: ephall@nycap.rr.com Contact Person for Building & Code Compliance:_Ethan P. Hall Cell Phone:_(518)260-2888 Land Line: _(518)741-0268 Email: ephall@nycap.rr.com Addition/Alteration Application Revised February 2019 PROJECT INFORMATION: -sue^y w TYPE: ❑ Commercial X Residential WORK CLASS: X Single-Family ❑Two-Family ❑Multi-Family(#of units ❑Townhouse ❑Business Office ❑Retail ❑ Industrial/Warehouse X Garage (#of cars_1.5 ) ❑ Other (describe ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE: 1st floor:_425 1st floor:_578 2nd floor: 2nd floor: 3rd floor: 3rd floor: Basement (habitable space): Basement (habitable space): Total square feet:_425 Total square feet:_578 ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $_35,000 2. If Commercial project, what is the proposed use: 3. Source of heat: ❑Gas❑Oil®Propane❑Solar ❑Other 1 Fireplaces need a separate Fuel Burning Appliances&Chimney Application 4. Are there any structures not shown on the plot plan? OYES ®NO Explain: 5. Are there any easements on the property? EYES NO 6. SITE INFORMATION: a. What is the dimensions or acreage of the parcel? _1.58 acres b. Is this a corner lot? EYES ®NO c. Will the grade be changed as a result of the construction? DYES ®NO d. What is the water source? PRIVATE WELL e. Is the parcel on SEWER or a PRIVATE SEPTIC system? _Private Addition/Alteration Application Revised February 2019 �' ^may DECI ARATION: 1. I acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within a 12 month period. 2. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to fees and department approval. 3. I certify that the application, plans and supporting materials are a true and complete statement and/or description of the work proposed,that all work will be performed in accordance with the NYS Building Codes, local building laws and ordinances, and in conformance with local zoning regulations. 4. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of occupancy. 5. I also understand that I/we are required to provide an as-built survey by a licensed land surveyor of all newly constructed facilities prior to issuance of a certificate of occupancy. I have read and agree to the above: PRINT NAME: _Ethan P. Hall —Architect\Agent for the Applicant SIGNATURE: _ DATE: 23 Aug 2019 Addition/Alteration Application Revised February 2019 FUEL BURNING APPLIANCE & Office Use Only CHIMNE. r• I-1 v :rmit#: -rmit Fee:$ O Town of Qgeensbury p 742 Bay Road,Queensbury, NY 12804 s ! k AUG 1 Z��9 voice:#: C� I P:518-761-8256 www.queensburv.net a `r li l TOM QUEEN IW DING&C2i'I/1�.S Project Location: Click or tap here to enter text. Tax Map ID#: Click or tap here to enter text. Room of Install: Click or tap here to enter text. Planned Install Date: Click or tap here to enter text. **ONE APPLICATION PER APPLIANCE** CONTACT INFORMATION: • Applicant: Name(s): David Howard Mailing Address, C/S/Z: 470 West Mountain Road, Queensbury NY 12804 Cell Phone: (518)361-3243 Land Line: (518)792-0222 Email: Click or tap here to enter text. • Primary Owner(s): Name(s): David & Diane Howard Mailing Address, C/S/Z: 470 West Mountain Road, Queensbury NY 12804 Cell Phone: (518)361-3243 Land Line: (518)792-0222 Email: Click or tap here to enter text. ►_� Check if all work will be performed by homeowner only • Installer/Builder: Workers' Comp documentation must be submitted with this application Contact Name(s): Click or tap here to enter text. Contractor Trade: Click or tap here to enter text. Mailing Address, C/S/Z: Click or tap here to enter text. Cell Phone: ( ) Land Line: ( ) Email: Click or tap here to enter text. Contact Person for Building & Code Compliance: Ethan Hall - Rucinski Hall Architecture Cell Phone: (518)260-2888 Land Line: (518)741-0268 Email: ephall@nycap.rr.com Fuel Burning Appliance&Chimney Application Revised February 2019 FUEL BURNI1IPPLIANCE INFORMATION: TYPE OF DEVICE: ❑ Stove ❑ Fireplace Insert ® Fireplace O Fuel Fired Equipment(Garage Only, 18" clearance per IMC 304.3) ® Fireplace,factory built** (**Manufacturer's name: Quadra-fire Model#: QV-32 or equivalent SOURCE OF HEAT: O Wood ❑ Coal 0 Pellet ® Gas CHIMNEY INFORMATION: O Masonry(require plans to be submitted): O block 0 brick El stone ❑ Flue: ❑ tile ❑ steel ❑ size, in inches ❑ Material*: ® double-wall ❑ triple-wall ❑ insulated (*Manufacturer's name: Quadra-fire Model #: Click or tap here to enter text. ) ADDITIONAL INFORMATION: 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: ETHAN P. HALL—ARCHITECT\AGENT FOR THE APPLICANT SIGNATURE: Ic ext. DATE: 23 Aug 2019 Fuel Burning Appliance&Chimney Application Revised February 2019