RC-0068-2023 Office Use Only
ADDITION/ALTERATION PERMIT Perm it
APPLICATION
Town ofQucensbury Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Invoice#:
Flood Zone? Y Reviewed Bob
Project Location• `' � 'Or) I!-e_
Tax Map ID#: .3 — / 7 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 t►—r'jn,)S
ADDITION SQUARE FOOTAGE: ALTERATION SQUARE FOOTAGE:
1st floor: 1st floor: V-11,
2"d floor: 2"d floor:
3rd floor: 3rd floor:
Basement(habitable space): Basement(habitable space):
Total sq ft: Total sq ft:
Scope of work to be done: FjnL 4ig6;, l J aZGL .
()au n J rv) Z, I-A
Addition/Alteration Application Revised June 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 ❑ 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. 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 If,for any reason,the building permit application is withdrawn,30%of the fee is retained by the Town of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 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: ��Il�-�N DATE:
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): f
Mailing Address, C/S/Z: IN y
Cell Phone:_ (S/9 ) B a — Land Line: 3 /Q U
• Primary Owner(s):
Name(s): �G7tt
Mailing Address, C/S/Z: I��. r� �/' fga-,er5 1171- /s pu V /ate/f
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): (f7)14S CaF-
Contractor Trade:
Mailing Address, C/S/Z: /Q lcce-
Cell Phone: ( S/d ) 6#4 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: -�;7`�CO>;c�
Cell Phone:,_) Land Line: M4
Email:
Addition/Alteration Application Revised June 2022
Inspector s'io.:
COMMONWEALTH ELECTRICAL.INSPECTION SERVICE, INC. .
(Consulting and Fire Inspection Services)
(Incorporated in the states of New York;Pennsylvania, and West Virginia)
Desiring Certificate of Approval, application is made for inspection of electrical installation in.the premises described below. On
demand,applicant agrees to pay for inspection service in accord with schedule of.charges
:
Owner: 1 it h
Type Building:Dwelling Other.(please specify). ;'
Job Location: City: { State:
County: 1.-._j . Permit From: Permit / 1
Swimmi
ng Pool: Inground: .. _ Aboveground: Bonding Date:
Work-New Additional Bldg.- New Old Ready for Inspection
Applicants Signature: License#:
Please Print Name: Phone#:
Applicants Address: Name of Utility:
City: Office To Be
State: Zip: Notified: .. . Job#:
SPACE BELOW FOR USE OF INSPECTORS ONLY
Switches / Water Heater Service Equipment Other list below
C, Receptacles Paddle Fan/Light Control Service Equipment
GFCI Rece t Paddle Fan Panel
AMP Rece t Paddle Fan/Light / Dryer Rec
Lights 1 Vent Fan Washer Rec
Lights Air"Conditioner, 'Dishwasher Red
Smoke Detectors AFCI Breaker Microwave Rec
Smoke/CO Detectors GFCI Breaker Garbage Disp Rec
�,, 1 ., , r• AFCUGFCI Breakers Refrigerator Receptacle
Additional apparatus for certificate:(Not listed above) Inspector Job Notes:
ROIN MuiMBLO
Electried Inspector
1 State Street
Glens Falls, NY 12801
(51-8) 7.9 -0905
Installed By(if other than applicant):
OFFICE USE ONLY
Extra tripdates Ins ection Fee $ .7��.00
Date Received: Service Date: 1 CASH
Certificate No: R.W.Date: _;-1 v.- 2 Check No.
Final Date: (;- =,.1_3 3 Invoice
Certificate Needed? 4 CC
Date Sent: Inspector sign in ---,
Yes_Dup next space l /
Please print name Inspector:
Original Progress Final
THIS APPLICATION EXPIRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S.INC.
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