RC-000374-2015 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
CERTIFICATE OF OCCUPANCY
Permit Number: RC-000374-2015 Date issued: Wednesday, November 25, 2015
This is to certify that work requested to be done as shown by Permit Number RC-000374-2015
has been completed.
Tax Map Number: 289.7-2-4 2')f5 1
Location: 12 MOON HILL PL
Owner: GARFIELD RAYMOND
Applicant: GARFIELD RAYMOND
This structure may be occupied as a:Replacing mobile home out of park(previous
home removed due to fire,see demo permit 2014-360) By Order of Town Board
TOWN OF QUEENSBURY
Issuance of this Certificate of Occupancy DOES NOT relieve the A
property owner of the responsibility for compliance with Site Plan, /d
Variance,or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
at 742 Bay Road,Queensbury,NY 12804-5904 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: RC-000374-2015 b l? 'ZZ 15- 1
Tax Map No: 289.7-24 REVISED
Permission is hereby granted to: Ronald Morehouse
For property located at: 12 MOON HILL PL
In the Town of Queensbury,to construct or place at the above location in accordance with application together
with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform
Building Codes and the Queensbury Zoning Ordinance
Te of Construction
Owner Name: GARFIELD RAYMOND Mobile Home $0.00
Owner Address: 421 Bay RD Total Value $0.00
Queensbury,NY 12804
Contractor or Builder's Name/Address Electrical Inspection Agency
Plans&Specifications
Replacing mobile home out of park(previous home removed due to fire,see demo permit 2014-360)
PERMIT FEE PAID-THIS PERMIT EXPIRES: Friday,July 8,2016
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the pion date.)
Dated at the To�of Quee ury;
T 2015
SIGNED BY: for the Town of Queensbury.
Director of Building&Code Enforcement
MOBILE HOME APPLICATION Office Use Only
4c,-aoo64.4 -2o6
A / Received
DATE: ""o, Tax Map ID Z�'l• -2�g
p Permit No. (5-
TAX MAP ID ll b ��• �',�- Permit Fee �S
PROPERTY LOCATION: A&)v. �'
NAME OF MOBILE HOME PARK: D � _�yJ �{Q C r (�q{2G� J.-
PROPOSED DATE OF PLACEMENT: MAY 18 2015 I` 1✓`L✓� I/W II .J, a"O l7
7WN OF QUEENSBUR,'
APPLICANT ING 8 CODEbwNER
ADDRESS C ADDRESS
PHONE �I t�-? r YS- PHONE
NAME OF INSTALLER OR MOBILE HOME DEALER
ADDRESS: l�- MQUI'� /( �QIT � .3 SOI De 06 ylfi,.
PHONE
CONTACT PERSON FOR BUILDING&CODES COMPLIANCE: PHONE:
COMPLETE INFORMATION BELOW FOUND ON A"PLATE"OR"STICKER"WHICH IS AFFIXED TO THE MOBILE HOME
Insignia serial number
Name of Manufacturer Sec c T4 ,(?
Place Approval Number
Model or Component Designation (New home only)
Date of Manufacture: y4
e17 66_5
MOBILE HOME INFORMATION ZONING INFORMATION
Approximate Value of Home $ ,t U 0 t9 O Zoning
" .p
New Home or Replacement Due fu hAlr Size of property ft.by ft.
Size of Mobile Home �ft,by ( � tL Existing buildings
Singlewide or Doublewide S ,• (e Accessory buildings o .
Number of rooms(exclude bath) S Storage buildings
•
Number of Bedrooms 3 Detached Garage O
_ —2 _3
Number of Bathrooms Z Attached Garage —1 _2 —3
Gas Fireplace;Woodstove or Wood Fireplace Setbacks Front yard: ft.
No Rear yard: ft.
Side yard: ft.
Foundation Support Size Depth Water Supply - I,. a !/ Well: ✓
n 3 c cQP. Piers r'x''f4 e,f Municipal:
/ Runners -x I' a`
Slab p77-c 077 Septic Permit Required? Yes r✓ No
Town of Queensbury Building& Codes1
Mobile Home Application July 2014
Procedure for placing and occupying a mobile home or modular home:
1. Application is submitted and review: 2 copies of plot plan and layout must accompany application along with
septic application (if needed) and fee.
2. Permit is issued— Permit card is placed on property
3. Footing forms are inspected before pouring concrete: Home is placed on foundation or piers
4. Arrange for electrical inspection—see "Certified Electrical form" on Town website
5. Septic Inspection, if needed
6. Final electrical Inspection
7. Stairs & platform covering door width and door swing with handrails on both sides of platform and stairs are
required for all exterior doors.
8. Final inspection by Building & Codes Department
9. All mobile/manufactured housing must be anchored to the ground upon which they are site per
manufacturer requirements.
10. Installer Warranty seal must be provided at the time of Certificate of Occupancy
11. If anchoring is not possible due to weather conditions or any other item, a Temporary Certificate of Occupancy
will be issued; Fee-$10; Deposit$100.00 (refunded when all items are complete)
DECLARATION: I swear that to the best of my knowledge and belief the statements contained in this application,
together with the plans and specifications submitted, are a true and complete statement of all proposed work to be
done on the described premises and that all provisions of the Building Code, the Zoning Ordinance, and all other laws
pertaining to the propose ork sh a completed wit , whether specified or not, and that such work is authorized by
the owner. Installer Wa a ty will rovi d7' e f Certificate of Occupancy.
Print Name: Date:
fFbwner,I g nt, Contractor
Signature: l�S Ca,4,1 ed l� �c, yV11 V Date: l l j—
Special Conditions of Permit:
By: Code Enforcement Officer
2
Town of Queensbury Building&Codes Mobile Home Application July 2014
SEPTIC DISPOSAL APPLICATION Office Use Only
Received
DATE: ���/� �� Tax Map ID
TAX MAP ID:
- Permit No.
Permit Fee
ZONE:
APPLICANT 6'� O 9�� PHONE/E-MAIL �
ADDRESS l/f v 6 �� �[.� rG 'y c -e C�/
INSTALLER/ PHONE`/E-MAIL
BUILDER
OWNER
ADDRESS �, c z O
CONTACT PERSON OR/BBbILDING&C DE COMPLIANCE:
PHONE/E-MAIL �`7 y ` 1!X3
RESIDENCE INFORMATION
Year Built #of bedrooms X gallons per bedroom =total Daily flow
1980 or older p6 Garbage grinder installed Yes No
1981-1991 Spa or Hot Tub installed Yes No
1992-Present
PARCEL INFORMATION
Topography Flat rolling _Steep slope %Slope
Soil Nature Sand AL, Loam Clay Other
Groundwater At what depth:
Bedrock/Impervious material At what depth:
Domestic Water Supply Municipal Well(if well,water supply from any septic system absorption is_ft.)
Percolation Test Rate: per minute per inch(test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION
Tank size 0vD gallons(min.size 1,000 gallons,add 250 gallons to size for each garbage cylinder or spa or hot tub
System Absorption field with#2 stone Total length 6 U ft.;Each Trench massa
Seepage Pit with#3 stone How many: ;Size
Alternative System Bed or other type:
Holding Tank System Total required capacity? Tank size 1,006 #of tanks
Notes: 1)Alarm system&associated electrical work must be inspected by a Town approved electrical inspection agency;2)We will
no longer allow systems to be covered until such time as an As-Built plan is received&approved. The installed system must match the
septic system layout on file—no exceptions.
Declaration: Any permit or approval granted which is based upon or is granted in reliance upon any material representation or failure
to make a material fact or circumstance known by or on behalf of an applicant, shall be void. 1 have read the regulations and agree to
abide by these and sally uirements of the Town of Queensbury Sanitary Sewage Disposal Ordidinan e. {
PRINT NAME: v D f{J D6rz DATE:
SIGNATURE: DATE:
Town of Queensbury Building&Codes Principal Structure Application Revised September 2014
Oct. 14. 201512:43PM M01A No. 1989 P. 1/12
MIDDLE DEPARTMENT INSPECTION AGENCY, INC.
i�that the electrical wiring to the electrical equipment listed below has been examined and is approved as
being in accord with the National Electrical Code, applicable governmental, utility and Agency rules in effect on the date
noted below and is issued subject to the following conditions.
Owner: Garfield Raymon Date: 10/06/2015
Occupant: Double Wide Location
12 Moon Hill Place
Occupancy- Ingle Family Dwg, Queensbury, Warren Co. NY
Applicant: �
Lawerence Henderson
PO Box 262
Lake George NY 12845
L J
Joseph A.Holmes
No; 318.01.4195657EL _ - - - .. _ _ - - _ - _ _ _ . - - - - - -.
Equipment:
1 -150 Amp Feeder To Home; 150-Amp. Service Equipment 4/0
This certificate applies to the electrical wiring to the electrical equipment listed Immediately null and void. This certificate applies only to the use,occupancy and
above and the installation inspected as of the above noted date based on a visual ownership as inoicated herein. Upon a change in are use.occupancy or ownership
inspection. No warranty is expressed or implied as to the mechanical safety.effl- of the property indicated above.this d rdffcate shall be immediately null and void.
ciency or nmess of the equipment for any particular purpose. This certidcale shall In the event that this certificate biroomes invalid based upon the above conditions,
be valid for a period of one year from the above noted oete. Should the electrical this certificate may be ravalidated upon reinspection by Middle Department
system to which this certificate applies be altered in any way,including but not limit. Inspection Agency,Inc. An application for inspection muss be submitted to Middle
eo to,the introduction of 6odlUenal elselricel equipment endlor tine replacement dF DYDartment Inspection Agenoy. Ina.to initiate the inspection antl revalidation
any of the components in Ilia as of the above noted date,this certificate shall be process. A fee will be charged for this service.
Town of Queensbury Building & Code Enforcement
Office No. (518) 761-8256
Septic Inspection Report
Inspection request received: 4;., I ►b
Name: r41rQIIhoU,. 2J Inspected on: 1 20445
Location: Arrive: M.
Permit No.: Inspector's Initials:
om ents and/or diagram
Soil Type Sand m I Clay
Type of Water: MuniicipaCWell Water
Waterline separation distance ft. LayV
Well separation distance ft.
Other wells: --L(0 ft.
Well Casing Length 50'+/- _Y_N_NIA
[150'to well required if NO]
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft. �1
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type MDBti
Building to lank LA%% SDN E
Tank to Distribution Box qt L
Distribution Box to Field/Pit LAL`
Opening Sealed: N C 1\
End Cap — E l�-�pQtr� \r)' ti'�1P `� 4, F►yc
aPipes&Baffles
Manholes
Manholesles g 12"or less below rade _Y_N
[provide extension collar if Yes] —Y—N
FoQ 5 EQ F \� T AtJ1L
Location/Separations
Foundation to tank • ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan _Y—K 2 )&-bI7,j�j L n
Engineer Report and As-Built —Y N �T�
ETU Maintenance Contract provided
Location of System on Property:
Front Rear Left Side Right Side Middle FrontMiddle Rear
System Use Status: C> Y D
proved �J
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
Septic Inspection Report
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: am • Depart: c amJpm
742 Bay Rd., Queensbury, NY 12804 Inspectors Initials' i.A /;/
NAME: e....1 IF ' ^ Q.A. PERMIT NO.: _ ,-,– n
LOCATION: !`2., KI.,c.. ►MEW i•!. INSPECT ON: MIF
RECHECK: _
Comments and/or diagram
1 Soil Type: SandLoam/ Clay
Type of Water: Municipal Well Water
Waterline separa n distance ft.
Well separati distance ft.
0 er wells ft.
Well Casing L ngth 0' + / - Y N N/A
[150'tow II requir if N44]
a ,.,-,„,-_,_(2
Absorption Feld: Total le gth ft.
Length of each tr-nch ft.
Depth of tre cher ft.
Size of Stone
Seepage Pits: .umber
Size: x
S •ne Size: t/ ---11/%-1\2- K
'aping Size Type
Building • tank d--a-
Tank Distribu F "•n Box (;1
Distributionn Box to F eld/ Pit `-�
Openin. Sealed: _Y N - ,�,
End Cap YY NN F-t__--/Z_ �✓ �Inlet/Outlet Pi' s &Baffles Y N o
Manholes 12"or less below grade _Y N � \e `k
[provide extensioncollar if Yes] Y N �`
Location/ Separations
Foundation to tankft.
Foundation to absorption _ _ ft.
Separation of Pits ft.
Conforms as per Plot Plan T Y N
Engineer Report and As-Built _Y N
ETU Maintenance Contract Y N
provided
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Status:
Appro te- d 1
artial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
L:\Pam Whiting\2010\Building Codes Forms\Inspection Forms\Septic Inspection Report_03 29 10.doc el)
Town of Queensbury Building & Code Enforcement T1
Office No. (518) 761-8256
i13
Septic Inspection Report
Inspection request received: 9 l \ 15
Name: ''1/ Itsti&V"-ei Inspected on: 9a `�
Location: 2 OOr��I \ Arrive: ... .m 1 p
, 32'
Permit No.: 15-1-3 Inspector's Initials: 11111Igirr
�44Q`k(NA_— C.#nts and/or dia•ram
Soil Typ— an. oam/Clay
Type of la er: Municipal/Well Water
Waterline separation distance ft. Lail52—1610
Well separation distance ft.
Other wells: ft.
Well Casing Length 50'+/- Y N N/A
[150'to well required if NO]
Absorption Field: Total lengthft. VK k
Length of each trench ft.
Depth of trenches '? ft. - ,
Size of Stone C 7/
�/
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank vT \, NNV-R
Tank to Distribution Box IA\! L`
Distribution Box to Field/Pit y" \ C._ 1-- Lk� \" 'W __::::----
Opening Sealed:
IIN
Encl
nl t/OutO es&Baffle2N � ` �� ��
M s 12"or less below grade Y N
DNi-1
[provide extension collar if Yes] Y N
Location/Separations V----t ‘ U.Y t Ll. -1(3 a \___I t, '
Foundation to tank ft. 1�� M IFI..__ V. C---c
to absorption . ft.
FP—___.
Separation of Pits ft. ��
Conforms as per Plot Plan Y N N N
Engineer Report and As-Built Y N
ETU Maintenance Contract provided Y N
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Status-
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved41
Septic Inspection Report
i
Foundation Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/pm Depart: pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials:
NAME: PERMIT#: tiN VT3
LOCATION: ( INSPECT ON: `� t tt
TYPE OF STRUCTURE: v
Comments
Y N N/A
Footings
Piers
Monolithic Slab
Reinforcement in Place
The contractor is responsible for
providing protection from freezing
for 48 hours following the placement
of the concrete.
Materials for this purpose on site.
Foundation/Wallpour
Reinforcement in Place cfrktsk
Footing Dowels or Keyway in place
Foundation Dampproofing
CQ`� cat7�C.
Foundation Waterproofing V
Footing Drain Daylight or Sump
Footing Drain Stone:
12 inch width
6 inches above footing
6 mil poly for wet areas under slab
Backfill Approval
Plumbing Under Slab
PVC/Cast/Copper
Foundation Insulation Interior/Exterior
R-
Rough Grade 6 inch drop within 10 ft.
L:\Building&Codes Forms\Building&Codes\Inspection Forms\Foundation Inspection Report.doc
Last printed 12/9/2014
Foundation Inspection Report l—
Office No. (518) 761-8256 Date Inspection request received: 111-161b
Queensbury Building&Code Enforcement Arrive: am/pm Depart:1i m/pm
742 Bay Rd., Queensbury,NY 12804 Inspector's Initials. ! rq.
NAME: �16(e \OU C- PERMIT#: \rJ"r1-3
LOCATION: d Aiocxi -R0ccQ INSPECT ON: T}-1 G-I'
TYPE OF STRUCTURE: )Mht'te 6tvie.
Comments
Y N N/A
Footings
Piers
Monolithic Slab
Reinforcement in Place
The contractor is responsible for
providing protection from freezing
for 48 hours following the placement
of the concrete.
Materials for this purpose on site.
Foundation/Wallpour
Reinforcement in Place
Footing Dowels or Keyway in place
Foundation Dampproofing
Foundation Waterproofing
Footing Drain Daylight or Sump
Footing Drain Stone:
12 inch width
6 inches above footing
6 mil poly for wet areas under slab
Backfill Approval
Plumbing Under Slab
PVC/Cast/Copper
Foundation Insulation Interior/Exterior
R-
Rough Grade 6 inch drop within 10 ft.
L:\Building &Codes Forms\Building &Codes\Inspection Forms\Foundation Inspection Report.doc
Last printed 12/9/2014
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