CC-0724-2022 Office Use Only
ADDITION ALTERATION PERMIT ? -Zp?�Z.
Permit#: �.. ��'
Town of(J,ucensbury APPLICATION Permit Fee:$ 20n
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Invoice#: t)(0
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Flood Zone? Y bN Reviewed By:
Project Location: 2 I(o Qtq#kfy, 9
Tax Map ID#: 3DZ . $ — - �{'� D Su c ivision
DEC 0 8 2022
PROJECT INFORMATION: TOWN OF QUEENSBURY
BUILDING&CODES
TYPE: ❑ Residential C•7i Commercial, Proposed Use: p{n�1'5 +
❑ Single-Family ❑ Two-Family ❑ Multi-Family (#of units_) ❑ Townhouse
❑ Business Office WrRetail ❑ Industrial/Warehouse ❑ Garage (#of cars )
G'Other (describe jjf'ypr Pen4t - C V5 - MOO 5- lot 114 t4jre ss f 1rre )
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: W4 wi 6-e 3oacl.6ynnwrrir5 } J5 k.►.q Dv+ -fir &►frele .1 Vc
W'i X% O%G 06 W h 4- P*DvSc fta Cd go�iSc d 0;V r . W.e hvo k'�26
�K�O 9�1�i�i( a.a.i �I�P4r 'fP nAI 1 7a i/Oh , Th-vre TS A 6Qe Se-e�-,cK ac,fs'de .
6 C�t�t F 1-!o►^ we Idi a Il be he* A '►!i -i•.I& l'ts 0,0!e P-klele 4T
h/e l ( . We yl„ ►t be yoay ox;►u!T f/v So r+ �a P fi ®prex SFr.
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Addition/Alteration Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ , B®0
2. Source of Heat (circle one): by 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 VNO
• Will the grade be changed as a�/result of the construction? ❑ YES M NO
Lid• 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 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: E a%t T 54q 1*y
SIGNATURE: DATE: Z o 4 Z
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 17i15 fPofk t Drcsj
Mailing Address, C/S/Z: Z `ow•6-e- �y4rre,, I-) Q8Y w� 1 Z 4o y
Cell Phone: f( i 1 ) 7 4 6-0 837 6 Land Line: f( a $ ) ZRQ - T 19 y
Email: -e 54i pity c� ; bs S>r..7 &c . Ca a..-_
Primary Owner(s):
Name(s): Rckin :nvocr4 LL L
Mailing Address, C/S/Z: 3`$8 Mg In 0.0e
Cell Phone: 77 ) ZS y - 22q-7 Land Line:
Email: on 1KIncti 'a-)mMre�' .Cow- DR ;cc,,'0 PraMire ; *or'
❑ 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: 01
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 project: tA.c. T 5 Au e
Cell Phone: Srt- ) l4,G-0SS(Q Land Line: Sr ) 7q - !9 y
Email: -e On.-ale„ 6f f eg li'c - (c,....
Addition/Alteration Application Revised June 2022
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full compliance With ithe Building Poc!0' of
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New York
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December 16, 2022
To Whom It May Concern,
All Aspen Dental practices use digital X-ray machines to take images of patients'teeth.Aspen
Dental has not used chemicals for producing X-rays in greater than 4 years.
If there any further questions, please feel free to reach out to me.
D � CEa � E
DEC 16 2022
TO1 uN�D NG&CODES Y ._
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Sincerely,
KowcvvM. KuVtk,, CPC
Karin M. Kurtz, CPC
Manager, Licensure and Certification, Compliance
Karin.kurtz@aspendental.com