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application Office Use Only ` C-- °la7- c0Ih j MANUFACTURED HOME Permit#: (Z PERMIT APPLICATION Permit Fee:$ ( 50 , 00 Town of Queensbury 742 Bay Road,Queensbury,NY 12804 _ __--•------��— r so P:518-761-8256 www.queensburv.net ( . . �k i ; u J ' \ 11-,1 \ - ----indlice#: 0 L/ 3 v lys''a MAY 222018 ; ' ___ _kt 30?. q-l- �3 (J �.� g M �.. _ -p Project Location: (� • Tax Ma ID #: - Name of Park: yri V _ 1 Q+ Proposed Date of Placement: Pt-Srk 1 CONTACT INFORMATION: • Applicant: Name(s): -4Coflf:) \c1 in Mt -6 VAS- - Mailing Address, C/S/Z: 'Z \1 Cr o vt-k-- r Q Lowry ri. _5O 12 - Cell Phone: ( . 'Ig) 910 --'9(a 1� Land Line: (,�IS�' ) goof -- I44.s- Email: Mr) 'n ©I'-€ tA-e 1 Q 9 on 6i 1 . (-0 WI • Primaryn Owner(s):2 Name(s): ,0t,t11nk-kd 0 tryvo(..e..ovSe_ Mailing Address, C/S/Z: g (IY\&ijri-- you€ UU-e?,r2 tStpur\t VIA/, (2.SZO1-1 Cell Phone: ( - i ) -IC{ (..o -- - (O lc Land Line: ( ) Email: • Contractor(s): Business Name: 1Z©n VIA (5Ve 1t.itS-C.- Contact Name(s): Mailing Address, C/S/Z: ' '' \ .Q_C(y1# Ik f u bVi,:e e . _P ux'SlOY V' t� , Y?.'0(4 Cell Phone: ( $T t4") 10t tLC, -- 1 Land Line: ( ) l Email: ter\'m.D ce. IDULSC-1 9 Y1A RI I -C"Z('Y"� , 66 of 40 tontact Person for Building & Code Compliance: 1©rl totto( k , . (SA Phone: (S )19(0 --q(p(& Land Line: ( ) (o, Email: ron (\-j lD e, BnAve6A • Co 04 Town of Queensbury Building&Code Enforcement Manufactured Home Application Revised May 2017 MANUFACTURED HOME INFORMATION: (INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME): Insignia serial #: Q 'Q V _ l3, \,'t L-t1 'Z2 Name of Manufacturer: . p `V. ( Place approval#:Model or component designation (New Home Only): \\,1 �QPk('V\ /Anc le Date of manufacture: ` ADDITIONAL INFORMATION: 1. Approximate Value of Home: $ 9500. 00 _ 2. Is the home NEW or a REPLACEMENT X ? �6- LK-74,r tr11. 3. Single-wide x or Double-wide ; Size: ft.X `'1' ft. 4. Foundation support (choose one): Size Depth Piers: Slab: 5. Is the home being placed on a private lot? No Yes X (if yes,you must provide stamped engineered drawings of the permanent foundation plan) 6. Total#of rooms(exclude bathrooms): 3 ; #of bedrooms: Z ;#of bathrooms: 7. Additional heat source? No Yes Choose one, if yes: gas fp',( woodstove_ wood fp 8. Are there any other/existing buildings on the property? No X Yes ; Explain: 9. What is the water source? PUBLIC PRIVATE WELL 10. Is the parcel on SEWER or a PRIVATE SEPTIC system? pi .‘V fk4e_ S' �- 11. Do you need a septic permit application? No_ Yes )( 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 NYS Building Code,the Zoning Ordinance and all other laws pertaining to the proposed work shall be completed with I have read and agree to the above: PRINT NAME: V.0cw-`d m� SIGNATURE: \ r‘A Mom!vSIUlAraA DATE: J4O Town of Queensbury Building&Code Enforcement Manufactured Home Application Revised May 2017 GILSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only 742 Bay Road,Queensbury,NY 12804 ToHn of cjuecnsbun P:518-761-8256 www.queensburv.net Permit#: Tax Map ID#: �'y Permit Fee: $ ; Invoice#: Project Location:6 a o�/, 9�e • Septic Variance? Yes No Primary Owner(s) • 1l ge444/J 12Z05'f o ce,- Mailing Address c V 69u /L,' [ si3'6 K Phone & Email 5" 7"6-2 /c Installer/Builder -k � SM rrL Mailing Address6? g\/ Phone & Email c)' ) �C/ a9S f Engineer Mailing Address Phone & Email Contact Person for Building&Code Compliance: Phone: ( Oi 690 RESIDENCE INFORMATION: Year Built Gallons #of bedrooms X gallons per =total daily flow per day bedroom Garbage Grinder Yes N 1980 or older 150 Installed? (circle one) 1981-1991 130 Spa or Hot Tub Yes Installed? (circle one) 1992-Present 1103 -:',-' llb 33(J PARCEL INFORMATION: Topography / Flat Rolling Steep Slope %Slope Soil Nature `J Sand Loam Clay Other Groundwater At what depth? NA Bedrock/Impervious material At hat depth? Ai 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 OW gallons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub System Absorption field with#2 stone Total lengthy ft.; Each Trench yo ft. Seepage Pit with#3 stone How many: ; Size: Alternative System Bed or other type: Holding Tank System Total required capacity? ;tank size ;#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 and approved. The installed system must match the septic 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. I have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. ,,,y� J l PRINT NAME: A--D S/w d+'" DATE: &/ A/) I DATE: SIGNATURE: ./I��14:/ Q� Town of Queensbury Building&Code Enforcement Revised March 2018