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
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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:
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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
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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