CC-0747-2022 ME 0WK Office Use Only
ADDITION/ALTERATION PERMIT Permit#:_CC — 03a- 202:7-
Town ofQuc bury APPLICATION permit Fee:$
742 Bay Road,Queensbury,NY 12804 t)lS!/ q-CD7
P:518-761-8256 www.gueensbury.net Invoice#:
Flood Zone? Y N Reviewed By: �
Project Location:
Tax Map ID #: '� ��Z���j 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:
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: �v� �- �C.� �U GYe.Q��2
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Addition/Alteration Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 2bti`SO
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? 0 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 If,-for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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 a certificate of occupancy.
I have read and agree to the above:
PRINT NAME:
SIGNATURE: DATE:
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): � � '�( QJI��
Mailing Address, C/S/Z:
Cell Phone: ( 5,-)1 ) 310 l 2k Ln Land Line: Z—
Email:
Primary Owner(s):
Name(s): S �.
Mailing Address, C/S/Z:
Cell Phone: Land Line: rD� ' ) f:!V'j�
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"
• Architect(s)/Engineer(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:
Cell Phone: �_) Land Line: )
Email:
Addition/Alteration Application Revised June 2022
309.11-2-36 CC-0747-2022
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Hayes & Hayes
4 Western Ave S
Commercial Interior Alterations
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