RC-0694-2023 ik
Oib Office Use Only
"-- 1 ADDITION/ALTERATION PERMIT Permit#: l C — 04'y L/— Zv 3
fo f
�APPI' Lrmit
Town of Queensbury �ftWEE {IVIE --Tk Fee:$ Aa 0, aO
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net 11
1 OCT 30
2023 J nvoice#: 6,7 oo
'food Zone? Y ) Reviewed By:6 /
TOWN or--:Du I~NSBURY
BUlL�Da\K: &: CODES `� (�,,
Project Location: '3 " V' U° i'� Qutefil"r1 NI
Tax Map ID#: Subdivision Name:
. PROJECT INFORMATION:
TYPE: rig Residential ❑ Commercial, Proposed Use:
El 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: illy ci IVi,ir,�ji r..G! `'A-A- )ci5e1M C7' l cc t S
araw. tfr
c.1��'Ire/t2� av►l v (ury 5 -'or kori6rvoinek
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'act I IS -41 e. 42eV / tr IL5 gui,./c,i 5a t-
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Addition/Alteration Application Revised June 2022
1
ADDITIONAL PROJECT INFORMATION:.
1. Estimated Cost of Construction: $ 6Q.
I'2. Source of Heat(circle one): ❑ Gas i�`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 Vitr40 Explain:
4. Are there any easements on the property? ❑ YES ;A�NO
SITE INFORMATION:
• Is this a corner lot? ❑ YES ,1N.O
• Will the grade be changed as a result of the construction? ❑ YES dit5NO
• What is the water source? ❑ PUBLIC PRIVATE WELL
• What type of wastewater system is on the parcel?EWER XRIVATE 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.
P)1.� &,,. - .
;- ' 2,';"aIf,for any reason,the building permit application is withdrawn, 30%of f.t, the fee is retained by the Town of
Queensbury.After 1 year from the initial application date, 100%of the fee is retained.
3�fthework 'is.not completed by the 1 year expiration date the permit may be renewed, subject to fees
-� .? `and department approval.
i ' certify th t 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
E ordinances, ani in conformance with local zoning regulations.
!-^ Y K : yy ,
40 II acknowledge that priorr,,to occupying the facilities proposed I, or my agents, will obtain a certificate of
occupancy. -, alit i
l- k 'ri A to
(5, ppap understand�l/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.
YCd j:,, Y .-
,
pi G }MIagreef ' above
_
.„
r']. yr: '"�
PRET MINE % .*
SIGNATURE: e
DATE: II. ititi 92'---.
' �lr-`,A;v iM
4
3ryc kL '
' 61 Revised lune 2022'
Q rolifi IIY sakErb A r.1 cation ,.2...� � #
,,
ADDITIONAL PROJECT INFORMATIO :
1. Estimated.Cost of Construction: $ 5Zi (°5 C)
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? ❑ YES62 NO Explain:
4. Are there any easements on the property? ❑ YES DiNO
SITE INFORMATION:
• Is this a corner lot? ❑ YES 4 NO
•._ Will the grade be changed as a result of the construction? ❑ YES lO
• What is the water source? 'UBLIC ❑ PRIVATE WELL
• What type of wastewater system is on the parcel? ❑ SEWER 6PRIVATE 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:
SIGNATURE: Ines 1C` DATE: /O.2o-233Addition/Alteration Application Revised June 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): . efrwe5 PvI
Mailing Address, C/S/Z: •'if tw'_r ict,K !"�� �'�" ��"�' /� (a, e7
� Y l�
Cell Phone: ( SLR ) 1`l5 c01,5-1 Land Line: (
Email: i Purc l S1iZt & \ • ( d�"\
• Primary Owner(s): l
Name(s): c ti bou AO-
Mailing Address, C/S/Z: 311 cleverAte, kk ctom5 ,Jr
Cell Phone: ( fig) ) ����' 1�, Land Line: ( )�
Email: Chrk.S o- CGc)v n��r� e� C
❑ 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): 4i_ Jc4
Contractor Trade: twi/W1til
Mailing Address, C/S/Z: J
Cell Phone: •( toy ) ' - 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: It okcaY1`-\---.
Cell Phone: ( ) Land Line: ( )
Email:
Addition/Alteration Application Revised June 2022
Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): rilvvcS pe d Gc" S
Contractor Trade: ijecittJ 0'41
Mailing Address, C/S/Z:
Cell Phone: cit—11Zr 27�(D Land Line:
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Addition/Alteration Application Revised June 2022