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CC-0722-2022 Office Use Only I E N--� ADDITION/ALTERATION PERMIT Permit#:C'C- 0-�2Z -- 2022— Town ofQueensbury APPLICATION permit Fee:$ 200 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Invoice#: Flood Zone? Y n Reviewed By: AS— Project Location: Tax Map ID #: �� Subdivision Name: PROJECT INFORMATION: DEC 7 201? TORN OF EN TYPE: ❑ Residential Commercial, Proposed Use: > , eU LD1NQVE SBU " S ❑ 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: Total sq ft: Scope of work to be done: -L-1 Ok C* y d Addition/Alteration Application Revised June 2022 ADDITIONAL PROJECT INFORMATION: 1. Estimated Cost of Construction: $ _4J O0 0 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 ❑ 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. I 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of.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 certificate of occupancy. I have read and agree to the above: PRINT NAME: SIGNATURE: DATE: L/ Addition/Alteration Application Revised June 2022 y` , -1 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL Name(s): Mailing Address, CM: Cell Phone:-O 3 ( (�� �L Land Line: �) Email: • Primary Owner(s): Name(s): . Mailing Address, C/S/Z: YIN 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): Contractor Trade: Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: � ) Email: "Workers' Comp documentation must be submitted with this application" • Arch itect(s)/En gin eer(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: AM n�-� Cell Phone:�_) Land Line: �) Email: Addition/Alteration Application Revised June 2022 i 1�!�����i:�■■.Vi'i■ii.�1■■i-�M��.�i■■1.1■[I■■ ■■e■■■■■■ ��►�■■ ■mm ONE i■■■■■■■■■■■ N■ 01 1■n■■■■■■ii No i■i ■■Q��ii�� laii■■■■■■■■■■I■■■■ ■� �■■i�■■1 �1'1t1:.1i�1�:�_ •► • ��C��Ilii■■■ii■■I�■iii NMI ■■■■ui■!!."opffis 0001001■■ii■■■■i■■■■ ■M■■■EM I■■ _Si►��ie�.��iii■iii.\iil.■■■ ■ol ■■■■�■■■Ir �i==ii "'iiiOMEN i■IRViN.■■■ MIN MMINERIMIN 01 mm =a ANEE W■■■■■ice � � �► ��■■ �� ■ii■■■ t�.i1■■■i■E. r-W_iil ONE W ■Ei■■1.iii ■��i�\■■gin► ■■■■Milli ■■1.■■■ i■■nmmmZMl \ ■■■Fol , ; , � ' i1�?!�fl■■■1■■■■ ■n MEMO■■■ON-%MEEK 7,4 N■■N1■iieWHO MN MEN Nunn mmmm:m ■ r ■■NASA m"Ai►•�1 •�1?�ii■■ l�■i�ri��ti rI■■■ ■C!■■■■s■■■■■NEE■■■■■in©m .311001■ ■mmoff�■■■■■■■i.■i■■■■■►il1" ■■■■■I m■■■ ia`_N■KEn■■■■■■■■■■■i■■■i`a■■■i■■Im■■■ Erii n■■iii■iii■■■■II ■■■ ■i►�■■■i .' : loom i■niNOON i■i■i■i■In■i■ iiii■ii�s iiiii■■n■■■i■m■■i■■■i■■■ilR■■ ■■■■■i■I■■■■■■f C�%l�i �Gi■■i■MIN■■iill■■■ ■in■■■I0■■■■■■J0�1 mogPl.imii■■■■■Im■■■ ■■■■■■ ■■■ � ' iliiiiiiifirmii■■i■min■■ ■■i■■ii■■i/■ Ein■■i■■■■■■I�■■■ ■iii■ i'/■it �nlllllt'��;[ ! . 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