CC-0360-2021 ���C� ll'ee-Y►S��lf� • 'YIC�
Office Use Only
ADDITION/ALTERATION PERMIT Permit#: Ct--Q 5(o 0 - 28 2 I
APPLICATION
Permit Fee:$
Town of Qucensbury
742 Bay Road,Queensbury,NY 12804
Invoice#:
P:518-761-8256 www.gueensbury.net
Flood Zone? Y N Reviewed By:
Project Location: /I Vol 14ey,
Tax Map ID #: (�v �►Sb` r� t2Toq Subdivision Name:
PROJECT INFORMATION:
TYPE: Residential X/ Commercial, Proposed Use: Av+p Se ice_ C�:,•(-
_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:
31 floor: 3rd floor:
Basement (habitable space): Basement (habitable space):
Total sq ft: Total sq ft:
Scope of work to be done:
�e_elc-Ce "wt.,1 J c., 'F nA
p E C E 9 V E
MAY 14 2021 01
TOWN OF QUEENSBURY
BUILDING&CODES
Addition/Alteration Application Revised January 2021
l
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 7 S oo
2. Source of Heat (circle one):_Gas _Oil _Propane _Solar_Other
Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application
3. Are there any structures not shown on the plot plan? YES X NO Explain:
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 NO
• 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 certifythat 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 a certificate of occupancy.
I have read and agree to the above:
PRINT NAME: AIM
SIGNATURE: DATE: y 2/
Addition/Alteration Application Revised January 2021
i
I
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Alm A VYI(46.1 Ohm Vt k�a g Car 51-(L-c-4;On
Mailing Address, C/S/Z: IVY I Zg-y 6
Cell Phone: ( 10' ) 7 9't � I 1 2 7 Land Line:
Email: Co,)Skcvc+�� �yvl`K���S� cVhgr
• Primary Owner(s):
Name(s):
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): AW m LPI)
Contractor Trade: Gar�Jrc,z fsro 1411 e>A,5e_
Mailing Address, C/S/Z: g )aYlsr Ct,
Cell Phone: 746 I12 7 Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• Arch itect(s)/Enei nee r(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line:
Email:
Contact,Person for Compliance in regards to this project: 4�� �� / �1 /Agr,
Cell Phone: Kir ) 2 70 - 4F 5`10 Land Line: f )
Email:
Addition/Alteration Application Revised January 2021
0
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): A l`w /AC-b`,60^
Contractor Trade: V 1411b Co,6V("4"n
Mailing Address, C/S/Z: 9- )av%j5,A C-I, LG.14e—o zzs.�&- JVy 1Z1'y6
Cell Phone: S)K- 74t-112.7 Land Line:
Email: �OnStCuGfic/t by Vi Ic,'4,t6 °� y)",
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor 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
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:-
0 Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land-Line:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Addition/Alteration Application Revised January 2021