applications t �r
PRINCIPLE STRUCTURE Office Use Only
PERMIT APPLICATION � ��
Permit#: 1�� (D
Town&Queens my Permit Fee:$ `)(O 5 aJ[)
742 Bay Road,Queensbury, NY 12804 *Rec. Fee:$ 6ri)
P: 518-761-8256 www.queensburynet
Invoice#:1-53
I L�
Project Location: -e RII19Q �aN
Tax Map #: . �,— ( ` a9 Subdivision Name:
TOWN BD.RESOLUTION 86-2013:$850 recreation fee for new dwelling units: single family, duplexes/two-family,
multiplefamily, apartments,condominiums, townhouses,and/or manufactured &modular homes,but not mobile
homes. This is in addition to the permit fee(s).
CONTACT INFORMATION:
• Applicant:
Name(s): jQ�Jq/q Ohio_✓pV2SC5 Li-L
Mailing Address, C/S/Z: Sol, kct1 R 1 , Fob} idv.rd, my , )asJY
Cell Phone: (91`6 ) 796- 11611 Land Line: ( )
Email: yoi J„aol6n1-Ark ®Y*lip- .
• Primary Owner(s): � � � 0 �
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: ( ) JUL 2 3 2019
Email:
TOWN OF QUEENSBURY
El Check if all work will be performed by homeowner only BUILDING&CODES
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): 13Q51,ttiA t-hie 0/7 50 LL<-
Contractor Trade: UWevz( (_o fOretkr
Mailing Address, C/S/Z: ,4), j f L/ , A4' r /,),�J
Cell Phone: (5l6 ) 796 - 1/6( Land Line: ( )
Email: 1vt i J Q O t,e41,(41ra ),(O y.jaf pa-e411
**List all additional contractors on the back of this form
• Architect(s)/Engineer(s):
Business Name: k + 1 15
Contact Name(s): )69 N 60.6104 gd, Q�Q�s� A( I 404
Mailing Address, C/S/Z: 167 Ravi(Gkn omeths64v1 IVY 11` (
Cell Phone: ( S14 ) 60- 7y99 Land Line: ( S($ ) 7(45-Ow1
Email: •i-ti,1-1c1oo Q) + InS Q_k,9 �yi+
Contact Person for Building & Code Compliance: frliLikilel 6M1Ar
Cell Phone: {Si% ) 7g6-46(i Land Line: ( <0( ) -7 1. -clrl)
Email: leum,a44,
Principle Structure Packet Revised February 2019
,
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): T. D, 1306I etr
Contractor Trade: C,F.tir,Vea-2 pp�Mailing Address, C/S/Z: 75 kel' qh ►�y1 dud i FF(is,/VY, 1)t729
Cell Phone: ( ) 3 61 - Land Line: ( )
Email: /0130144,CrCa-c-vo e 0 ill Sh • co-v
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): �ojo Sdk UPS
Contractor Trade: UY iI
Mailing Address, C/S/Z: J�3 ethhK po,(40/5 C,G✓he /Hy 1459
Cell Phone: ( S ) ‘6c(5-'769 Land Line: ( )_
Email:
• Contractor(s): Workers' Comp documentation must be submitted with this application
Contractor Name(s): p (,
Contractor Trade: ; f
Mailing Address, C/S/Z: (d (,-ui. ;pr.,1y s 04
Cell Phone: ( c(( ) ago -3(}c y 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: ( )
Email:
Principle Structure Packet Revised February 2019
PROJECT INFORMATION:
TYPE: _Commercial Residential
WORK CLASS:
Single-Family _Two-Family _Multi-Family(#of units )
Townhouse Business Office Retail Hotel/Motel
_Industrial/Warehouse }Garage(#ofcars ) _Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
1'floor: 13%_ 1'floor: 39/
2"d floor: 2nd floor:
3rd floor: Total square feet: 3 9
Basement(habitable space):
Total square feet: /3OO.46
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $ 100,(iQd
2. Proposed use of the building: ( (2 Ar,iI,� R,Staentt
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat. Gas) Oil Propane Solar Other:
(Fireplaces need a separate Fuel Burning Appliances&Chimney Application,one per appliance)
5. Are there any structures not shown on the plot plan? YES NO Explain:
6. Are there any easements on the property? YES NO
7. SITE INFORMATION:a. What is the dimensions or acreage of the parcel? 1 $6' - 15-o
b. Is this a corner lot? YES 40
c. Will the grade be changed as a res II. e construction? YES OD
d. What is the water source? • BLI PRIVATE WELL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? p yl li44c Cgp4L
Principle Structure Packet Revised February 2019
44,
DECLARATION:
I. I acknowledge that no construction shall commence prior to issuance of a valid building
permit and work will be completed within a 12 month period.
2. If the work is not completed by the 1year expiration date the permit may be renewed,
subject to fees and department approva I.
3. I certify that the application, plans and supporting materials are a true and 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.
4. I acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a
certificate of occupancy.
5. I understand that I/dve 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: friG(.i,plQt 3 &i �t;i(it
SIGNATURE: )21; dpQ 9 . (22oJi/-L DATE: 1 - 19
Principle Structure Packet Revised February 2019
•
Office Use Only
lltSEPTIC DISPOSAL PERMIT APPLICATION Permit#: — `1• 25:31
Permit Fee: $ ; Invoke#:
Town or<Luccn.bun• Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 297.6-1-29
Project Location: Ridge Road
• Applicant:
Name(s): Beshara Enterprises, LLC Mailing Address, C/S/Z: 4 Jon Kay Road Fort Edward, NY 12828 D IE (�v L UM E
Cell Phone: ( 518 ) 796-4612 Land Line:
Email: michaelbeshara2@yahoo.com u JUL 2 3 2019
OF
• Primary Owner(s): TO BUILDING N D&CODES QY
Name(s): same as applicant
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
gCheck if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
• Engineer(s):
Name(s): Hutchins Engineering
Mailing Address, C/S/Z: 169 Haviland Road Queensbury, NY 12804
Cell Phone: _( ) Land Line: ( 518 ) 745-0307
Email: tutchins@hutchinsengineering.com
Contact Person for Building & Code Compliance: same as applicant
Cell Phone: ( ) Land Line: ( )
Email:
Septic Application Revised February 2019
•
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes lip
1980 or older 150 Installed? (circle one)
Spa or Hot Tub Yes Q
1981-1991 130 Installed? (circle one)
1992-Present 110 proposed 3 bdr 110 330
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand _Loam _Clay _Other(explain:
Groundwater At what depth? presumed seasonal high water table at 26"
Bedrock/Impervious material At what depth? Greater than 49"
Domestic Water Supply ✓ Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 5:35 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1.000 gallons(min. size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with #2 stone Total length 200 ft.; Each Trench 50 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 and 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. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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.
PRINT NAME: ih;(1,4t1 J- /sl4rq DATE: l • l4
SIGNATURE: 4 DATE: y— 1 i9
Septic Application Revised February 2019