RC-0132-2021 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: EC- 1-1314'0=
APPLICATION
Permit Fee:$
Town of Quccnsbury
742 Bay Road,Queensbury,NY 12804
Invoice#:
P:518-761-8256 www.gueensbury.net
Flood Zone? Y ON Reviewed By: AJ S
Project Location:
Tax Map ID#: 301.17-3-16 Subdivision Name: Sherman Pines
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:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total sq ft: NA Total sq ft: NA
Scope of work to be done:
Change 2 - 8' wide overhead doors to 1 - 16' wide door
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GCE E
MAR 2 2 2021
TOUEENSBURY
WN
O &CODES
Addition/Alteration Application Revised January 2021
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ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ $5000
2. Source of Heat(circle one):_Gas _Oil _Propane _Solar_Other NA
Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application
3. Are there any structures not shown on the plot plan? YES NO Explain: NA
4. Are there any easements on the property? YES _NO
SITE INFORMATION:
• Is this a corner lot? _YES NO
• Will the grade be changed as a result of the construction? _YES V NO
• What is the water source? Z PUBLIC _PRIVATE WELL
• What type of wastewater system is on the parcel? SEWER VPRIVATE 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 I/we are required to provide an as-built survey by a licensed land surveyor of all newly
constructed facilities prior to issuance of certificate of occupancy.
I have read and agree to the above:
a h Digitally signed by Matthew J
PRINT NAME: Matt 1 1 eW II Cifone
g`�� :cn= a ew i one,
SIGNATURE: • � o.=Gne Const.Co.Inc.,ou, DATE:
te % aii=mci one@ci one.com,c= S
'y Date:2021.03.18 09:32:48-04'00'
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Addition/Alteration Application Revised January 2021
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CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Applicant:
Name(s): Matt Cifone
Mailing Address, C/S/Z: Pn.Rnx 6R4 rlPna FnIISrNY 12801
Cell Phone: ( 518 ) 361-0626 Land Line:
Email: mcifone@cifone.com
• Primary Owner(s):
Name(s): C onnr Mrr)nnntioh MnrkPn7iP Cif one
Mailing Address, C/S/Z: 20 Ailtilmn I nne QLieen<hury isl)t l28o4
Cell Phone: ( 518 ) 788-0720 Land Line: � )
Email: MLC2678@gmail.com
❑ 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): Matt Cifone CIFONE CONSTRUCTION CO INC
Contractor Trade: General Contractor
Mailing Address; C/S/Z: PO Box 684 Glens Falls, NY 12801
Cell Phone: 518 ) 361-0626 Land Line: 518 ) 792-9242
Email:
"Workers' Comp documentation must be submitted with this application**
• `Architect(s)/Engineer(s):
Business Name: American En!gineerinq
Contact Name(s): George Yasenchak
Mailing Address, C/S/Z:-A-�ioltjino StCIo sFalJs�J)t 1280.1
Cell Phone: ( 518 ) 421-9245 Land Line: ( 518 ) 615-0201
Email: georgeyas3@yahoo.com
Contact Person for Compliance in regards to this project: Matt Cif one
Cell Phone: 5( 18 ) 361-0626 Land Line:
Email: mcifone@cifone.com
Addition/Alteration Application Revised January 2021
MAP REFERENCE D
MAP ENTITLED "SHERMAN PINES SUBDIVISION' ��� �0ry�,l
DATED•JAN. 25, 1993, SHEET 1 OF 12
MADE BY MORSE ENGINEERING P.C.
. FILED IN WARREN COUNTY CLERK'S OFFICE ON t
JANUARY 29, 1993, PLAT CABENET A SLIDE 197 '
TOWN OF QUEEfVSBU/ 1 ,T��
LO-SULDING& CODESI 1 l E LA
,ggo.49 2 ,•.•.• � '. ,
.100.00, me I HEREBY CERTIFY TO::
KOREY J. ROZELL
LOT 4 *y TRUSTCO BANK OF NEW YORK, ITS SUCCESSORS AND/OR ASSIGNS
O EPARED FROM AN ACTUAL FIELD
10,500 SF SUREPARE
VETH THAT YIS MAP ACCORDINGORD DESCRIPTIONS AND SHOWS
�1 LOCATIONS OF BOUNDARIES AND IMPROVEMENTS ON THE
PREMISES AND THERE ARE NO ENCROACHMENTS OTHER
THAN SHOWN
V O ;C(YUS '`��/ ' THIS SURVEY AND THE CERTIFCATIONS HEREON SHALL BE
pR�,STbryE 7 1 ( VALID ONLY TO THE PARTY OR PARTIES HEREON NAMED AND
ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS OR
j •1"� Q O' r SUBSEQUENT OWNERS, OTHER THAN AS MAY BE OR
0
}A ~ ^1• EXPRESSLY STATED HEREON
p)
DAVID A BOLSTER
aum• DATE : JUNE 30, 1994
Na0• • o ;r 0o,
r 49 , �! FILE COPY
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g1112 731¢ r
y ��
r '
N Recel15 LOT 5 MAP OF A SURVEY OF LOT 4 SHERMAN PINES
r TDWp of N �1�munrty ! MADE FOR
\ peeensbury �, �0; �L LA rie" '
Idg:DePL �L �„ . B°<^�`�� KO.REY J � ROZELL
F ti '_� ra •^ m� I I
Be lot � °*.0 '°
TOWN OF OUEENSBURY, COUNTY OF WARREN, SPATE OF NEW YORK
DAVID J. BOLSTER
'UNAUTHORIZED ALTERATION'•OR ADDTITON TO A SURVEY
ryYry T RItRhV MAP BEARING A LICENSED LAND SURVEYORS SEAL IS;A LICAREND.LAND SURYdYDR, QUjsNSDURY, NII YDRS
POII VIOIATIDN OF SECTION 7209,8UB-DIVISION 2. OF THE
NEW YORK STATE EDUCATION LAWYJ
ONLY COPIES FROM THE ORIGINAL OF,THIS SURVEY DAVID J. BOLSTER DATE JUNE 29. 1994 SCALE: 1" 30' N.Y.S. UC. N0. 48534
MARKED WITH AN ORIGINAL OF THE LAND SURVEYORS,
SEAL SHALL BE„CONSIOERED TO BE VALID TRUE COPIES,' DATE SEALED DWG. NO. 94083 B
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