RC-0227-2022 Office Use Only
ADDITION/ALTERATION PERMIT Permit#: 9-C* '022:—+
APPLICATION
Permit Fee:$
Town of Qucensbuq
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.gueensbury.net
Flood Zone? Y g)Reviewed BOVQZ�N
Project Location: s-C'a/\\.Wq W PC0 (D r.41'0 ag L4 S
Tax Map ID Subdivision Nam E nfl
PROJECT INFORMATION: 8 20 -2
TIC- J6.:E-NSDURY
TYPE: Residential El Commercial, Proposed Use: 0S
Singie-t a-mily El Two-Family El Multi-Fam.ily (#of units_) El Town
-
EI Business Office El Retail 11Industrial/Warehouse . El Garage t W of cars
El Other(describe
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor:
2nd floor: 2nd floor:
3rd floor: 3rd floor:
ft:
Lasement (habitable space): Basement (habitable space):
ft.
Totta sqq Total sq ft:
Scope of work to be done: a, e-,L;t
J S C'
lee-)V i-s Al
LJ 4, V3 6 4 "1 A 5
fLe-
0
C
C. 0-.s
Addition/Alteration Application Revised March 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $
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 ❑ NO Explain:
4. Are there any easements on the property? ❑ YES ❑ NO
SITE INFORMATION:
• Is this a corner lot? ❑ YES ❑ 1\191�
• 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 1vq 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 atrue 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: ( `A
SIGNATURE. DATE.
Addition/Alteration Application Revised March 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z:
Cell Phone: -L3LS-- ) �-! La (nd Line: L
Email:
• Primary Owner(s):
Name(s): kyle �S �� U .
Mailing Address, C/S/Z:
Cell Phone: Aand 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):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line: �)
Email:
"Workers' Comp documentation must be submitted with this application"
• Arch itect(s)/Engi 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 p oject: Ak--t C.A,-
- Cell Phone:� ) /Land Liner ( )
Email:
Addition/Alteration Application Revised March 2022
COPY[F:ILE COPY ,T
jL GLUEfNSBURY
GliraP�RTMENT
Based on our li Od examination,compliance
With our-comments Lshall--not-be-.construed-as----"--"-,
indicating jo specifications are in
L
full 'compliance with the Building Codes of
New York State.
T
. ....... ...
C-y
TOWN OF QUEENSbORY
BUILDING & COYESJDEPT.
Bb C
Reviewed
Date*
+
621,
239.7-1-32 RC-0227-2022
Restle, Charles
167 Assembly Point Rd
Basement Renovations (post const)