RC-0068-2021 Office Use Only
ADDITION/ALTERATION PERMIT Permit#:_�C— O®Co
APPLICATION Permit Fee:$
rMM orQueensbury
742 Bay Road,Queensbury,NY 12804 Invoice#: �v
P:518-761-8256 www.ciueensbuDL.net
q� Flood Zone? Y N Reviewed By:
Project Location: 45 ` 19d'5+r 5 6d m rnonS i Y eY
Tax Map ID#: ��o. �� Subdivision Name:
PROJECT INFORMATION:
TYPE: Residential Commercial, Proposed Use:
(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: 3�
2nd floor: 2nd floor:
31d floor: 31d floor: �--
Basement(habitable space): Basement(habitable space): --
Total sq ft: Total sq ft: 7"�
Scope of work to be done:
Ftoor"
Oho v,rz "r',e rrn o Q,,,P of e l e tila`I`o 12-
Retmove_ Pa.i., P k) n t k v I n't V'o o v'V--)
Addition/Alteration Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction:$500 0
2. Source of Heat(circle one):_Gas Oil _Propane Solar Other Ailk
Fireplaces/inserts need a separate Fuel Burning Appliances&Chimney Application
3. Are there any structures not shown on the plot plan? YES NO Explain: _
4. Are there any easements on the property? YES _NO
SITE INFORMATION:
• Is this a corner lot? _YES NO A.
• Will the grade be changed as a result of the construction? _YES NO 0 LI
• What Is the water source? PUBLIC PRIVATE WELL
• What type of wastewater system is on the parcel? SEWER _PRIVATE SEPTIC
DECLARATION:
1. 1 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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. ifthework is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
4. 1 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. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain 'a certificate of
occupancy,
6. 1 also understand that 1/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:
0
PRINT NAME: L ► h'd A/bre.e,1
SIGNATURE: DATE:_ ���D�/
Addit1WA1teraUon Applicat!on Revbo January 2021
V,
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: �}
Name(s):
Mailing Address, C/S/Z: 51 01 c> ,3 (e cx cQ 5 a 0
Cell Phone: )02.5?-9.3a'1 TOM J L Land Line: (.5/1)
Email: Cn a �1� 1� �C.Dl1Str�c`� ► an[io COvr�
• Primary Owners}:
Name(s): -Marc go,cr'>o�y )� Carve-V (da u b Lem)-
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line: �}
Email:
❑ Check if all work will be performed by property owner only
• Contractor(s): (List all additional contractors on the back of this form)
Contact Name(s): ��c.u�'�
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:�_) Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• Architect(s)/Engineer(s):
Business Name: )YlQ-ff'J-� IA s'J 4h r a
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project: )NQ�A icanT_
Cell Phone:_(_} Land Line:
Email:
Addition/Alteratlon Application Revised January 2021