RC-0065-2023 /rW - Office Use Only
ADDITION/ALTERATION PERMIT Permit#: Qom. — Co 5 2023
Town of Queensbury APPLICATION Permit Fee:$ 5.23
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net Invoice#: Ct2c11
Flood Zone? Y 701 Reviewed B •
Project Location: j'7 lac a-i U! ��f` c ;r,J �v �� /,0
� J
Tax Map ID#: .2-61 9- _2- I Subdivision Name: /C'.ref(17I
Zalto
PROJECT INFORMATION: E ( ,. II!`II! v 1 .'
TYPE: /Residential ❑ Commercial, Proposed Use:
TOWN OF OUEENSBURY
BUILDING&CODES
Single-Family ❑ Two-Family ❑ Multi-Family(#of units_) ■ ownhbtig-e=---
❑ Business Office ❑ Retail ❑ Industrial/Warehouse El 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: 6 5—r Total sq ft:
Scope of work to be done: ACCitf /b C.e-fZ/.ey L l �L Gef2- c i tdc 2c 4r�
krtelti-e_ k,fip
Addition/Alteration Application Revised June 2022
ADDITION/ALTERATION
Submission Requirements:
Jinvn of i q. (RESIDENTIAL.AND COMMERCIAL)
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 unAnv.queensbury.net
1. Completed Addition/Alteration permit application(please print neatly or type)
2. Workers Compensation insurance information for ALL contractors involved in the project—this is
REQUIRED EVEN FOR SOLE PROPRIETORS
THREE (3) COPIES (either 1 pdf& 2 paper (min. 11" x 17") OR
3 paper (min. 11" x 17") OF THE FOLLOWING:
3. Structural drawings,which may include:
a. Signed&sealed architect or engineer stamp IF the cost of construction is over$20,000
b. Floor plan, if applicable
c. Foundation plan, if applicable
d. Cross sections, if applicable
e. Elevations, if applicable
f. Windows& door schedules,if applicable—printed on the drawings is acceptable
g. Calculation sheet for natural light, ventilation&emergency egress,if applicable—printed on the
drawings is acceptable
4. Plot plan,using a survey map,if possible,which includes:
a. Drawn to scale(i.e. 1 inch=30 feet)
b. Indicate the proposed changes with setbacks to the property lines
c. Include all structures on the property
d. Include the location of water supply(well or water lines)
e. Include the location&configuration of the septic system or sewer line
5. REScheck(for residential projects) or COMcheck(for commercial projects), signed and stamped, if
applicable—please visit www.energycodes.gov for more information
ADDITIONAL IMPORTANT INFORMATION:
1. Any changes to the approved plans prior to or 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.
Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Le.S'/i Ilia uci'cf.')
Mailing Address, C/S/Z: 024 eteiii.ru/d2 oC 1-cY'17-e q L.2�- k u,r It/• - /4a
Cell Phone; W17 027 7 5 56 , (K) Land Line: 3V •C/a-77 c,k C
Email: tiJLrr n Cr'-e‘2_1 eO a-v/ • CerK__
• Primary Owner(s):
Names &iie.:e_ gJ Cc,/"t-c_,'/
Mailing Address, C/S/Z: 24/ e_ec(.e2rr. nro c20)-, 'C. ou,-t f /tL t V,f , ' , /' 2 �1
Cell Phone: ,3'7 ar7 -596 6 Land Lifie: (-/
Email: ihrreK ete_cdL ot-e--/ . C-4,17C
❑ Check if all work will be performed by property owner only
• Contractor(s): (List allll/ ad itional contractors on the back of this form)
Contact Name(s): /n� £%'c/ Lz LLu4 '
Contractor Trade:,l'uh� c� 1 vx-� (eh�'
Mailing Address, C/S/Z: O. / � " °r74-P 1 tu.e.,c,. ka )i/I/� • / 2-Po
Cell Phone: 5/c- 3 0 7— 7/S f Land LG i ( s- 0 01-7i c
Email: ,2ito(liontJVta 'I, Cent
**Workers' Com 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: ,&et'(LL ie-i4_.
Cell Phone: ( c7 ) 3 o 1—71 fS Land Line: {5-/y ) 3 0 7-7/“S
Email: 41,2,(71 ,nti.,47,ctryi
I
Addition/Alteration Application Revised June 2022
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ '1-"7"" �� 3a°J U?lU
2. Source of Heat (circle one): I/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: /NO
• Is this a corner lot? ElYES
• Will the grade be changed as a r,esult of the construction? ❑ YES VNO
• What is the water source? Lt•PUBLIC ❑ PRIVATE WELL
• What type of wastewater system is on the parcel? ❑ SEWER El 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. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to fees
and department approval.
4. I 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. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy.
6. I 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: /Ai-
SIGNATURE: G DATE: t;:/ 423
Addition/Alteration Application Revised June 2022
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