RC-0063-2022 Office Use Only
j ADDITION/ALTERATION PERMIT Permit#: fz-C— 06 `3 "
APPLICATION permit Fee: $
Town of Queensbury
742 Bay Road,Queensbury, NY 12804
Invoice#:_ �J
P:51 8-761-8256 www.gueensburV.net
Flood Zone? Y DN Reviewed By.
Project Location:
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Tax Map I #�^ a—� = ` --� ubdivision Name:
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PROJECT INFORMATION: TOWN 0�: :Sr .IRY
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:
Addition/Alteration Application Revised January 2021
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ (gi"d
2. Source of Heat (circle one): _Gas _Oil APropane _Solar_Other
Fireplaces/inserts need a separate Fuel Burning Appliances & Chimney Application
3. Are there any structures not shown on the plot.plan? AYES NO Explain:
4. Are there any easements on the property? _YES IN 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 >D PRIVATE WELL
• What type of wastewater system is on the parcel? � SEWER X
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 If, for any reason,the building permit application is withdrawn, 30%of the fee is retained by the Town of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:
tl
Addition/Alteration Application Revised January 2021
,j
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): `^
Mailing Address, C/S/Z: Nvl� ��
Cell Phone: f Cl� )_ �Cc 3y Land Line: � )
Email:
• Primary Owner(s):
Name(s): Lci
Mailing Address, C/S/Z: 0\2 WN\ L�-$CN
Cell Phone: 0OX 3(Q\-- S kkI Land Line: � )
Email: okV_,c,, .0. L .Q Nvvax\ ,Cee
❑ Check if all work will be performed by property owner only
• Contractor(s): (List all additional contractors on the back of this form)
Contact Name(s): sor�. -aS
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• Arch itect(s)/Engineer(s):
Business Name:
Contact Name(s):
Mailing Address, C/S/Z:
Cell Phone: _�) Land Line: )
Email:
Contact Person for Compliance in regards to this project: ¢$,�L.
Cell Phone: S( 1� ) � -�''� Land Line: � )
Email:
Addition/Alteration Application Revised January 2021
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