applications Office Use Oniy
Z�
"
Permit#: ��,C�Udo l9 l'7
PRINCIPLE STRUCTURE PERMIT
�
APPLICATION
Permit Fee:$
rows of(Lecnsbury *Rec Fee:$ D S 0�
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Invoice#: 2- q 3 0
Project Location: 40 S +noy5,de
Tax Map ID #: S;.IY`00 5y Subdivision Name: -- - - __.--
*TOWN BD.RESOLUTION 86-2013: $850 recreation fee for new dwelling units, :i;�01
SLWOly,
multiple family, apartments, condominiums,townhouses, and/or manufactured Mill !
00t�lar homes, but not � i
homes. This Is In addition to the permit fee(s). NOV 1 b 2017 1
CONTACT INFORMATION: TOWN OF QUEENSBIJRY
€ UILDING&CODES
• Applicant: _
Name(s): �c-,-I( �I� �t�1-7
Mailing Address, C/S/Z: 1 g 4Loor*
Cell Phone: ( ) Y) 7- Land Line:
Email:— PSL- /5 SCO�� "C yl�c-J CG
Primary Owner(s): _
Name(s): N" 1 J t�� ti�G�
Mailing Address, C/S/Z: 39 iy
Cell Phone: 107 Land Line:
Email: � L C 410
• Contractor(s):
Business Name:
Contact Name(s): p41 I S
Mailing Address, C/S/Z: 5-S P,4-4e, G''t r4— ed- Y 7 42P'
Cell Phone: ( n- ) 3&7 - &Trf Land Line: � )
Email: /1e►v 2�� }.yS�.�.,
�T
• Architect(s)/Engineer(s):
Business Name: / 'r -�heo'o1 QL'S,'i Lo4, )�"�� G SSoL Iii J
Contact Name(s): En's i
Mailing Address, C/S/Z: PG 6cir 4c4d,&�
Cell Phone:�_) Land Line: 5� %!j" ) 7`x`7 010
Email: IJr�'a� @ hoc }�er� 2srg-,,�i.� e-n r.@ Rar KP/-n des ts-,
R�'Contact Person for Building & Code Compliance: ( J (-)I/-'`�`',,
Cell Phone: S( 1� ) ��7 $' ' Land Line:
Email: j l519
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
PROJECT INFORMATION:
TYPE: Commercial id I
WORK CLASS:
Asingle-Family Two-Family ...ulti--Family(#of )
Townhouse Bu;ines3 Office _Retail _Hotel/Motel
IndustrialMarehouoc- Garage(#ofcars Other(describe )
STRUCTURE SQUARE FOOTAGE: GARAGE SQUARE FOOTAGE:
11T floor: I 1 1 " 11T floor: ) , G y U
2nd floor: J/ 1 2 0 2nd floor: r3 G
3rd floor: Total square feet: , S 7 4
4th floor:
Total square feet: ,
ADDITIONAL PROJECT INFORMATION:
1. Estimated Cost of Construction: $
2. Proposed use of the building: Pe s, e,7 CjL—
3. If Commercial or Industrial, indicate the name of the business:
4. Source of Heat (circle one): Gas OilPro ane 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? YESL' Explain:
6. Are there any easements on the property? YES NO "
7. SITE INFORMATION:
a. What is the dimensions or acreage of the parcel?
b. Is this a corner lot? YES NO
c. Will the grade be changed as a result of the construction? YES NO
d. What is the water source? PUBLIC PRIVATE EL
e. Is the parcel on SEWER or a PRIVATE SEPTIC system? 5e0 f7�--
Town of Queensbury Building&Code Enforcement Principle structure App'�ation Revised February 20Ti
DECLARATION
i. 1 acknowledge that no construction shall commence prior to issuance of a valid b u i I ding permit and
work will be completed within a 12 month period.
2. If the work is not completed by the 1 year expiration date the permit may be renewed, subject to
fees and department approval.
3. 1 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. 1 acknowledge that prior to occupying the facilities proposed I, or my agents, will obtain a certificate
of occupancy.
5. 1 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: ���^� J
SIGNATURE: DATE:
Town of Queensbury Building&Code Enforcement Principle Structure Application Revised February 2017
FUEL BURNING APPLIANCEt, Office Use OnKi
CHIMNEY APPLICATION Permit#: +
Permit Fee:$
lurtnl(�urrtshure
742 Bay Road, Queensbury, IVY 12804 Invoice:#:
P: 518-761-8256 www.gueensbury.net
Project Location: S"^ny g,'de ens{' Tax Map ID #: S�3�a a50,
Room of Install: Qgse.ro f' Planned Install Date: �e 'xr k0i 17
**ONE APPLICATION PER APPLIANCE** v\�z�
CONTACT INFORMATION:
® Applicant:
Name(s): J
Mailing Address, C/S/Z: 44—
Cell Phone: S/Sf ) 30 7 9rJ'k 6 Land Line: _( )
Email: Ric- I qqo tz^o It 4a� cc.+ "t
• Primary Owner(s):
Name(s): Pa'-1
Mailing Address, C/S/Z: �� ��"✓lg /
Cell Phone:_( 37j- ) 107 — S—kj—U Land Line: _( )
Email: A M40 zc-V4 ye,4C.'C-.Ca--
® Installer/Builder:
Business Name:
Contact Name(s):
Mailing Address, C/S/Z• ' `,i P�L44, A,.c 1=�r4- �—
Cell Phone: _( S_�) 3G� `g'�"&U Land Line: _( )
Email: ? c /C7 yo y C
Contact Person for Building & Code Compliance:
Cell Phone: (S/b' ) 307 Land Line: _( 1
Email: Cr,wn
Fuel Burning Appliance &Chimney Application Revised March 2017
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove _ Fireplace Insert — Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
— Fireplace, factory built**
**Manufacturer's name: Model #:
SOURCE OF HEAT:
Wood _Coal _ Pellet _Gas
CHIMNEY INFORMATION:
— Masonry:
block brick stone
Flue:
_tie X steel Y size, in inches
_Material*: 4— S y.2+
4-
double-wall _triple-wall_insulated
V—aA-
(*Manufacturer's name: Model #:
ADDITIONAL INFORMATION:
1. Two inspections are required. A rough-in inspection, prior to installation and a final inspection, after
installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces & chimneys require plans to be submitted.
4. Twenty-four(24) hour notification is required for inspections.
Declaration:Construction/installation must conform to NYS Fire Prevention & Building Code and/or manufacturer
requirements. The applicant or owner agrees to comply with all applicable laws, ordinances, regulations and all
conditions that are part of these requirements and also will allow the inspector to enter the premises to perform the
required inspections.
I have read and agree to the above:
PRINT NAME:
SIGNATURE: DATE:
Fuel Burning Appliance &Chimney Application Revised March 2017
- FUEL BURNING APPLIANCE & Office Use Only
CHIMNEY APPLICATION Permit#: RG• "111 - Z-0 1'-t
- Permit Fee:$
limn of(Zirccu..bru •
742 Bay Road, Queensbury, NY 12804 Invoice:#:
P: 518-761-8256 www.gueensbury.net
Project Location: 40 S44?/7,S Je- e'134 Tax Map ID #: ��� y a9y. -� �z ' Z-
Room of Install: %�� r`�'"'� Planned Install Date: 7c�-�,
**ONE APPLICATION PER APPLIANCE**
CONTACT INFORMATION:
• A�licantt.:-
Name(s):
Mailing Address, C/S/Z: �► �`^��� �t-Q 1�-� �'-� /`'`�' l2k"2&-
Cell Phone: S( le ) 507 Land Line:
Email: (?-c
• Primary Owner(s):
Name(s): a—I
Mailing Address, C/S/Z: 35
Cell Phone:_(V? - Land Line: _( )
Email: 7110'-4-0-C'--eQ y-A 4 C+-'I
• Installer/Builder:
Business Name:
Contact Name(s): R-1 T C- -k4
Mailing Address, C/S/Z: 3 --, P�.J-o�-
Cell Phone: _(_S-7�- ) ?07 - Land Line: _( )
Email: p
Contact Person for Building & Code Compliance: r ' ,
Cell Phone: (57ov ) 3G7 FfFlJ;W Land Line: _( )
Email: @ ,4 C'
Fuel Burning Appliance &Chimney Application Revised March 2017
FUEL BURNING APPLIANCE INFORMATION:
TYPE OF DEVICE:
Stove Fireplace Insert _ Fireplace
Fuel Fired Equipment (Garage Only, 18" clearance per IMC 304.3)
Fireplace, factory built**
**Manufacturer's name: Model #:
SOURCE OF HEAT: ��//
_Wood Coal _ Pellet /�Gas
CHIMNEY INFORMATION:
_ Masonry:
block brick stone
` Flue:
tie steel size, in inches
�-
_Material*:
double-wall _triple-wall_insulated
(*Manufacturer's name: Model #: )
ADDITIONAL INFORMATION:
1. Two inspections are required. A rough-in inspection, prior to installation and a final inspection, after
installation.
2. Manufacturer's installation manual must be available at the time of inspection.
3. Masonry fireplaces & chimneys require plans to be submitted.
4. Twenty-four(24) hour notification is required for inspections.
Declaration:Construction/installation must conform to NYS Fire Prevention & Building Code and/or manufacturer
requirements. The applicant or owner agrees to comply with all applicable laws,ordinances, regulations and all
conditions that are part of these requirements and also will allow the inspector to enter the premises to perform the
required inspections.
I have read and agree to the above:
PRINT NAME: I J (�11`14°t'l
SIGNATURE: DATE: ti
Fuel Burning Appliance &Chimney Application Revised March 2017